Indigenous and Northern Affairs Committee on May 13th, 2022

[The Chair, Liberal, Marc Garneau]

Good afternoon, everyone. I'm calling this meeting to order.

Welcome to the twentieth meeting of the Standing Committee on Indigenous and Northern Affairs.

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

This is just a reminder, before we get going, about those 12 witnesses we had to supply for the fourth study by noon today, as well as the requirement for the rest of them by noon on May 20 so that the analysts can get on with inviting these witnesses.

Today, we are continuing our third study on the Administration and Accessibility of Indigenous Peoples to the Non-Insured Health Benefit, or NIHB, program.

I will get to our first panel in a moment, but first a few reminders.

I would like to remind everyone to abide by the requirements established by the Board of Internal Economy concerning physical distancing and mask wearing.

To ensure an orderly meeting, I would like to outline a few small rules. 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. Sometimes it has to go from Inuktitut to English and then to French, or vice versa, so there will be a little delay.

The interpretation button is found at the bottom of your screen with the choice of English, French or Inuktitut. If interpretation is lost, please le me know and we'll stop proceedings and try to rectify the problem before continuing.

Before speaking, please wait until I recognize you by name. If you use the “raise hand” feature, you can get my attention that way if you need to. If you are on the video conference, please click on the microphone icon to unmute yourself. For those in the room, as you know, your microphone will be controlled as normal by the proceedings and verification officer. When speaking, please speak slowly and clearly. When you are not speaking, your mike should be on mute.

As a reminder, all comments should be addressed through the chair. Also try to stick to the time that is allotted to you.

We start off with the witnesses each making a five-minute statement. Two of the three witnesses are here, so we'll get on with it.

I would like to welcome Dr. Lynn Tomkins and Dr. Philip Poon from the Canadian Dental Association. As well, Caroline Lidstone-Jones, chief executive officer of the Indigenous Primary Health Care Council will join us hopefully shortly. Finally, we have Maggie Putulik, vice-president, health services, Nunasi Corporation, who is in person today.

Without further ado I will invite Dr. Lynn Tomkins to start off our proceedings today.

Dr. Tomkins, you have five minutes.

[Dr. Lynn Tomkins, President, Canadian Dental Association]

Thank you, Mr. Chair.

Good afternoon, members of the committee.

I am speaking to you from Toronto on the traditional territory of the Huron-Wendat, the Haudenosaunee and the Anishinabe nations, and the Mississaugas of the Credit First Nation.

I am pleased to be joined by Dr. Philip Poon, who leads our subcommittee on the non-insured health benefits program and has extensive experience on this subject. He joins us today from Winnipeg, located on Treaty 1 territory and the homeland of the Métis people.

At the Canadian Dental Association, we know that oral health is an essential component of overall health, and we believe that all Canadians have a right to good oral health. That is why we are fully supportive of efforts by all levels of government to improve Canadians' oral health and to increase their access to dental care, especially for Canadians who need it most.

CDA has long advocated for investments in indigenous oral health and access to dental care. We have been collaborating for over a decade with officials who manage the dental component of the NIHB program and provide technical advice on its administration. Today, we would like to offer three recommendations in the context of your current study.

First, we are calling for better access to facilities where dental treatment can be performed under general anaesthesia. Many high-needs patients, particularly children, require dental procedures performed under sedation, specifically under general anaesthetic, and this requires a surgical facility. This is often the case for indigenous children who live in remote communities without access to regular dental care. These children often have severely decayed teeth, which can be difficult to treat in a conventional dental office setting.

Although the treatment is covered by the NIHB program, it is often a challenge to access the surgical facilities in which to provide the treatment. In many cases, hospital operating rooms are used. Even prior to the pandemic, it could be challenging to find the necessary OR space or staff. Treatment was often delayed for months, and this has all been worsened by the toll COVID-19 has taken on the health care system. The resulting surgical backlog means that this issue will likely persist for some time.

One option is to make better use of private surgical facilities that exist in many large cities. However, these clinics often charge rates significantly higher than the NIHB program's reimbursement levels, or they impose fees that are outside the standardized system of dental treatment codes, which are not reimbursed at all. Another option could be to construct dedicated, indigenous-run surgical facilities in communities that serve a high number of patients who qualify for the NIHB program.

Second, although the NIHB program compares favourably to other publicly funded provincial or territorial dental programs, some patients continue to face significant barriers in accessing care due to the program's burdensome administration. Many common treatments, such as partial dentures, require preauthorization, despite the exceptionally low rejection rates. The preauthorization process for other treatments, such as crowns, can also be more complex under the NIHB program compared to other dental programs, including the federal government's public service dental care plan.

Furthermore, other common services, such as night guards for bruxism, or tooth grinding, are included as a service under most dental plans, such as the PSDCP, but are not covered by the NIHB program.

The program has already made significant improvements in the past, such as removing the preauthorization requirement for root canal treatment. It's much appreciated. Given that indigenous oral health outcomes have lagged behind those of the non-indigenous population, the NIHB program should aim to facilitate efficient and quick access to care, rather than focusing on cause containment. We recommend that the program conduct a comprehensive review of the administration of dental coverage to ensure that any preauthorization requirements are in line with best practices of other dental programs, both public and private.

Finally, CDA applauds the historic investment in budget 2022. However, at a time when the federal government has committed to investing over $5 billion in dental care for Canadians, indigenous oral health must not be overlooked. As it currently stands, none of this funding targets the nearly one million first nations and Inuit in Canada eligible for the NIHB program. This may actually increase the significant oral health inequities between this group and the broader Canadian population.

The federal government should, in partnership with indigenous governments and other relevant stakeholders, develop an oral health investment strategy to improve the oral health of indigenous communities. Beyond the concerns outlined earlier, this could also include things like investments in education and awareness campaigns, public health programs providing preventative care, and access to clean drinking water and community water fluoridation.

Thank you for this opportunity to participate in the study of this important federal initiative. Dr. Poon and I would be happy to answer any questions that you might have.

[The Chair, Liberal, Marc Garneau]

Thank you, Dr. Tomkins. We're glad you could join us today.

Next will be Caroline Lidstone-Jones, CEO of the Indigenous Primary Health Care Council, who has now joined us.

Ms. Lidstone-Jones, you have five minutes.

[Caroline Lidstone-Jones, Chief Executive Officer, Indigenous Primary Health Care Council]

Aaniin, everyone.

As a representative from the Indigenous Primary Health Care Council, which supports indigenous primary health care organizations across the province of Ontario, we would like to thank the House of Commons Standing Committee on Indigenous and Northern Affairs for the opportunity to appear as a panel witness in view of its study, administration and accessibility of indigenous peoples to the NIHB program.

In providing feedback to the study on the non-insured health benefits program, we are doing so through the lens of an end-user perspective that is first nations, Métis and Inuit inclusive and solicitous of the northern, rural and urban indigenous communities we service here in Ontario. The four themes and observations we would like to report on are contained under affordability, accessibility, exclusionary and safety.

With regard to affordability, significant challenges noted for the northern, rural and urban indigenous populations include the following.

Many service providers, whether they be dental, optometry, pharmaceutical or others, require indigenous clients to play for their services up front and then independently submit receipts to NIHB for reimbursement. For some, this creates affordability challenges, as the services can be quite expensive. When looking at eyewear expenses, costs can be hundreds of dollars. Costs for emergency dental care alone can be upwards of thousands of dollars. For example, root canal therapy alone averages between $520 to $1,200 per tooth.

Plus, there is a general lack of awareness among service providers regarding the NIHB program, especially in urban settings. Many service providers are unaware of the program and their ability to access or register. As such, in many cases, indigenous clients are not offered the option of provider-submitted reimbursement. Therefore, in many cases, indigenous clients are not offered the option of having the provider submit reimbursement on their behalf. If the client requests direct billing to NIHB, it is often denied by the service provider.

On the other hand, many service providers who are aware of the NIHB program choose not to participate because of the predetermination processes and the length of time to process. In addition, it is reported by providers that the wait times to receive payment back from NIHB is extensive, so some providers are opting not to register as a provider or to remove themselves as a provider on the pre-approved registry list.

Finally, out-of-pocket costs for travel remain a significant challenge for indigenous peoples in northern, rural and urban settings. For those living in northern and remote regions, their out-of-pocket costs for travel continue to escalate with increasing gas prices. For instance, the fees for driving are currently established at 22¢ per kilometre. This fee is not keeping up with the costs of inflation, and it further impedes the affordability of individuals to access appropriate health care.

Comparatively, reasonable allowance rates that were identified on the Government of Canada website for 2022 were as follows: 61¢ per kilometre for the first 5,000 kilometres driven, 55¢ per kilometre driven after that, and, in the Northwest Territories, Yukon and Nunavut, there was an additional 4¢ per kilometre. In addition, meals are reimbursed at a maximum of $60 a day, compared to the Government of Canada website of $69 per day without receipts.

For the urban indigenous population, all travel is out of pocket, as access to designated NIHB medical transportation is minimal due to the expansiveness of service provision. Individuals travelling to urban settings for services are required to pay up front for taxi and parking. Both costs are extensive, especially in metropolitan areas, where a lot of the specialty services are housed. Parking alone can range upwards of $30-plus a day in the downtown core.

All in all, upfront and out-of-pocket costs for travel and services create significant affordability issues for those who may not have the affordability to do so up front. As a result, this may force them to abandon their much-needed care completely. When they eventually enter the system, we are now seeing them in emergency settings rather than in curative or in preventative-type settings.

There are some additional things that we see with regard to challenges. There is limited access to service delivered by indigenous practitioners. While there is an NIHB service provider list for mental health, it is mostly comprised of non-indigenous practitioners delivering mainstream services.

Developing a similar list and funding indigenous practitioners with an emphasis on traditional healing and wellness supports is essential to healing, especially when we accept culture as treatment and culture as healing. Reclaiming with culture, land-based healing and connecting with cultural service providers are well-known strategies that successfully support the indigenous population on their healing journeys.

Travel also poses additional challenges from an accessibility lens. Often the approval process for medical transportation is delayed or not expedited in a timely manner, especially if specialty services are accessed at the last minute. This results in clients having to cancel their appointments. We know that the wait times for most specialists and diagnostic testing is quite extensive so this then imposes further delays to their treatment and care.

Connecting with NIHB representatives in real time when experiencing an issue or having questions is a significant challenge. This is a well-known reason why service providers choose not to work with NIHB. It is a contributing factor to many indigenous people not receiving the care that they need. In many cases, out of frustration, they will abandon the process and not obtain supports through the NIHB program because of it being time-consuming, complex and labour-intensive to navigate.

[The Chair, Liberal, Marc Garneau]

Ms. Lidstone-Jones, you are six and a half minutes already, so could you wrap up, please?

[Caroline Lidstone-Jones]

Yes.

The final one I will focus on is racism in the health care system. Racism in the health care system is deeply rooted since the time of Indian hospitals, when they were created in the 1930s. Indigenous people experienced inequitable access to health care services and received subpar care. This often results in death.

When we speak about the anti-indigenous acts of racism, we reflect on the treatment of Joyce Echaquan, Brian Sinclair and others, but we also reflect on those who did not access much-needed services because it was too late or because of their anticipation of how they would be treated.

There is a significant gap in cultural safety and culturally safe care. We recommend that mandatory training be imposed on all NIHB services and service providers to ensure that safety is the ultimate lens.

We also—

[The Chair, Liberal, Marc Garneau]

Thank you. I'm going to have to stop you there.

Ms. Maggie Putulik, you have the microphone now, for five minutes.

[Maggie Putulik, Vice-President, Health Services, Nunasi Corporation]

Nakurmiik. Ullaakut.

Good afternoon, everyone.

Thank you, members of the committee.

My name is Maggie Putulik. I'm here today as the vice-president for health services for the Nunasi Corporation.

I would like to start off by saying that it is an honour for me to talk to you about the importance of the non-insured health benefits program for Nunavummiut Inuit. At the end of my presentation, I am going to outline three key recommendations to improve the policy.

Nunasi Corporation, which I work for, is a Nunavut Inuit birthright corporation owned by two regional Inuit associations, the Qikiqtani Inuit Association and the Kivalliq Inuit Association, and one regional development corporation called the Kitikmeot Corporation.

Ours is the oldest Inuit development corporation in the country. We were created in 1976 by the Inuit Tapirisat of Canada, at the time. It is now known as Inuit Tapiriit Kanatami. Nunasi Corporation was created to be used as a vehicle to ensure Inuit participation in economic development.

Nunasi has investments in the medical accommodations known as largas. We are situated in Ottawa, Winnipeg, Edmonton and Yellowknife. As there are no specialized medical services in the north, Inuit must be sent to the south to receive specialized medical services. The largas are known as a home away from home, with culturally appropriate programs offered to medical patients and their escorts. We provide accommodation, lodging and transportation covered by the non-insured health benefits program.

Nunasi also owns Polar Vision, which is located in Yellowknife but offers services for optical care in Nunavut communities.

The non-insured health benefits program is a significant program for Inuit, and although there are many benefits to the program, today I'm going to offer three specific areas of improvement that would greatly improve outcomes.

First of all, the federal government should enter into a long-term, 10- to 15-year agreement with the territorial Government of Nunavut to ensure that appropriate investments can happen. Long-term agreements provide greater certainty in securing the essential services we at the largas provide to Nunavummiut.

Second, the Government of Canada should develop and implement a territorial user transportation policy. I use the term “user”. In the medical world, a user is a patient or an escort. That's the term that is used. It should develop a territorial user transportation policy both for Nunavut and the Government of Northwest Territories to avoid misinterpretation of the policy pertaining to medical escort eligibility.

Escorts provide a critical function in Inuit health services. They accompany the patients and assist them with mobility issues and language barriers, as well as social, psychosocial and emotional support. We have experienced many inconsistencies in applying the escort policy, particularly in the GNWT. The federal government needs to implement a clear policy that specifically outlines who can be eligible to have an escort, because the policy as it is at the moment is vague and broad, and it could be misinterpreted by medical travel personnel, in particular, within those two levels of government.

Nunasi's third and final recommendation is to update the non-insured health benefits program policies related to vision care in Nunavut. Currently, the NIHB pays $300 to $400 for one pair of glasses every two years for adults and every year for children. These program benefits are below what is considered standard in vision care programs elsewhere in Canada.

We have been given the most basic amount to cover our glasses. We recommend that NIHB pay market rates or close to them for eye exams and glasses so that Nunavummiut can afford to utilize this program. As well, contact lenses should be included, and laser eye corrective procedures should be eligible in appropriate cases.

Finally, service days from opticians in the Nunavut communities are very limited. We frequently hear that the low number of available service days prevents Nunavummiut from accessing vision care. That is unacceptable.

As a professional who has worked in the health services network for the past 15 years and has been working diligently with the largas, Polar Vision and other health care providers that utilize the NIHB program, I have outlined for you today these three key policy recommendations. I believe that we could work collectively to make the program even better. I look forward to your questions.

Thank you for offering me the opportunity to appear before you today.

[The Chair, Liberal, Marc Garneau]

Thank you, Ms. Putulik.

We'll now proceed with the questions. We'll start with Mr. Schmale.

Mr. Schmale, you have six minutes.

[Jamie Schmale, Conservative, Haliburton—Kawartha Lakes—Brock, ON]

Thank you, Chair.

Thank you to the witnesses for their great testimony today.

In previous committee meetings, we've heard about the crippling level of bureaucracy within this program.

I think, Ms. Lidstone-Jones, you were just getting into a roll on that, and your time ran out. You're nodding. Would you like to complete your thought?

[Caroline Lidstone-Jones]

Yes, it's much appreciated.

We can speak from our Ontario perspective here for the communities that we service here. We're hearing that a lot of the resistance we have from current providers who are already registered or may have expressed an interest is because of the amount of bureaucracy and labour intensity tied to having to go through that process. It's something that they just don't have the time to do. This is especially in light of the fact that right now we are in massive HR crises, where recruitment and retention and the increased wait times become an additional burden on their time. [Technical difficulty—Editor] create supports to be able to do that.

It isn't necessarily that they are outright not interested in serving, but because of the bureaucracy tied to participating in the program, it becomes their choice to say that, for the amount of time it takes them to register, to go through all of the pre-approval and then the length of time for them to receive payment, they are just not able to keep up with the administrative burden to do that.

That has been something we are seeing, where more and more people are walking away from services because they can't afford to pay up front for them and then seek reimbursement from NIHB.

[Jamie Schmale, Conservative, Haliburton—Kawartha Lakes—Brock, ON]

Those people sadly just don't get the service they need.

[Caroline Lidstone-Jones]

Yes, and that's why we mentioned that many of them end up instead of in preventative stages—if we're looking upstream versus downstream—now entering into emergency where it's then more costly for the system to service them later on.

[Jamie Schmale, Conservative, Haliburton—Kawartha Lakes—Brock, ON]

Absolutely.

Just out of curiosity, are your members communicating with the department through fax?

[Caroline Lidstone-Jones]

Some are. It just depends on the location. We still have severe challenges. One of the recommendations we had also ties to not having.... We still have a major digital divide, especially for many of our remote first nations communities, so that becomes an ongoing challenge with the stability of Internet and lack of broadband, those kinds of things. That also adds further complexity to navigating the system. We have a combo of both.

[Jamie Schmale, Conservative, Haliburton—Kawartha Lakes—Brock, ON]

In a previous meeting, we had testimony from a pharmacist who talked about having to use a fax, because I guess email hasn't gotten to that department yet. He also mentioned that sometimes when you fax, the paperwork gets lost. Physicians have to start the process over again, and this also compounds the already frustrating system that exists.

[Caroline Lidstone-Jones]

Yes, and wait times.... If paperwork gets lost, the pre-approval process, then, is impacted. If you secure an appointment time and that paperwork is not done in time, that delays your travel, whether it be a flight, booking accommodations or whatever. It just trickles down and delays everything. We have had people miss their actual appointments because of the system failing in that regard.

[Jamie Schmale, Conservative, Haliburton—Kawartha Lakes—Brock, ON]

This lays out a pretty troubling road map, when you think about it—the fact that health care professionals are forgoing this because of the administrative burden that exists, the potential lost paperwork within the health care system in general, and then the fact that the payment takes so long to get. It's also to your point that preventative measures don't get completed at that time; you just get the worse case, which is going to the emergency room. In many parts of the country, we have hallway health care because our health care system is overwhelmed.

[Caroline Lidstone-Jones]

Absolutely.

[Jamie Schmale, Conservative, Haliburton—Kawartha Lakes—Brock, ON]

You mentioned that a bit in your testimony. Maybe you could expand on ideas you have or your organization has that could potentially relieve some of this pressure, at least the administrative burden, or even speed up the whole regulatory process that exists.

[Caroline Lidstone-Jones]

We have to find a better way around the paperwork system and the number of all of these pre-approvals, and then their having to take paperwork with them to prove they were at the appointment. It's not only leading up to the appointment. It's once you get to the appointment and the paperwork beyond that.

Sometimes you have people who also, because of the travel times and all that, miss getting the specialist to sign the paper and then that impacts their next travel, so it's all of those pieces. They don't realize that it's right from the start of the system up and down, and it then impedes their ability to get future access to the program.

What we need to do as health care providers is to really work together to establish a system on how we can more collaboratively tackle the length of time it takes the administrative bureaucracy to do this. We have had a few providers here in Ontario who took it upon themselves to administer the NIHB program, but the sad reality is that they experienced the length of time and delay for getting the process payment from NIHB as well. Then what happens is that it impedes the ability of the community to continue to travel because they don't have enough cash flow to be able to do that.

Again, I think that, when we're looking at the long term and in the long run, if we're again comparing upstream to downstream, it's so much less costly to catch them in preventative-type stages. When we get into acute care, we're already talking like there's something to diagnose and something to treat. We've now missed this whole part of the system here where we could have prevented worse-case outcomes or outcomes that require more types of treatment.

[The Chair, Liberal, Marc Garneau]

Thank you, Mr. Schmale.

We'll now go to Mr. Battiste.

Mr. Battiste, you have six minutes.

[Jaime Battiste, Liberal, Sydney—Victoria, NS]

I'd like to thank the witnesses for their testimony. We're hearing you loud and clear about the need, not only to ensure the prices and the costs are done more efficiently, but also the need to catch up in terms of what our government is providing.

When we're looking at some of the issues that are in the northern areas or rural and indigenous communities, one of the things that often comes into my head when I'm thinking about these problems is that often the challenge is that we have to travel as indigenous people to find the services elsewhere.

On the underlying issue of capacity on reserves or in the north, what can we do as a government to try to ensure that communities have the capacity so their community members don't have to travel off reserve or from the north? Is there a way in which we can work with universities? Is there a way we can create programs that increase the amount of indigenous participation in health?

Can you talk to us a little bit about any best practices out there in Canada right now that are working to increase the number of participants we have from the indigenous communities in the health studies?

I guess we could start with Ms. Lidstone-Jones.

[Caroline Lidstone-Jones]

Yes, absolutely. I can give you some concrete examples of our network here in Ontario with the Indigenous Primary Health Care Council. At our health care council, we are actually status-blind when it comes to providing service to indigenous peoples: first nations, Métis and Inuit. We have entered into a lot of relationship agreements with our first nation communities to bring care into those communities.

Where we are challenged, of course, is in our ability to have enough service capacity to do that. Right now, we are also trying to increase our capacity in the number of positions and primary health care providers that we get so that we can further our scope and our outreach.

We are also in relationship with the Northern Ontario School of Medicine, to talk about how we train our students, how we connect the western and traditional approaches to medicine and how we promote that internally in our communities.

The other thing that is advantageous to our system is bringing things such as presurgical clinics into the communities and gathering people who can do that, screening buses and things like that, where you can have captured people actually go for care. The other thing we have done is to institute mobile units. We were fortunate enough to get funds during times of COVID-19 to use as mobile units for testing assessments for COVID-19. We now have an opportunity and a system to have that for primary health care service delivery, which can take those services into the community to do more of those prevention type things.

Those are the things that we need to invest in to be able to take more services to the communities. Instead of communities having to go to where those services are, we need to look at the opposite to make sure that the accessibility is there.

[Jaime Battiste, Liberal, Sydney—Victoria, NS]

Ms. Lidstone-Jones, you talked about something that caught my attention, land-based healing, as an example of a promising practice within indigenous communities. Can you tell us a little more about that and how it's working effectively to address mental health, within indigenous youth especially?