THE STANDING SENATE COMMITTEE ON SOCIAL AFFAIRS, SCIENCE AND TECHNOLOGY
EVIDENCE
OTTAWA, Wednesday, October 2, 2024
The Standing Senate Committee on Social Affairs, Science and Technology met with videoconference this day at 12:03 p.m. [ET] to study Bill C-64, An Act respecting pharmacare.
Senator Ratna Omidvar (Chair) in the chair.
[Translation]
The Chair: Good afternoon. My name is Ratna Omidvar. I am a senator from Ontario and chair of the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
Today we are continuing our study of Bill C-64, An Act respecting pharmacare. Before we begin, I would like to ask my colleagues to introduce themselves to the people in the room and to the public.
[Translation]
Senator Miville-Dechêne: Julie Miville-Dechêne from Quebec.
[English]
Senator Osler: Flordeliz (Gigi) Osler, senator from Manitoba.
Senator LaBoucane-Benson: Good morning. Senator Patti LaBoucane-Benson, Treaty 6 territory, Alberta.
Senator K. Wells: Good morning. Senator Kristopher Wells, Treaty 6 territory, Alberta.
Senator Burey: Welcome. Sharon Burey, senator for Ontario.
[Translation]
Senator Mégie: Marie-Françoise Mégie from Quebec.
[English]
Senator Bernard: Wanda Thomas Bernard, Mi’kmaq territory, Nova Scotia.
Senator Quinn: Jim Quinn, New Brunswick.
Senator Pate: Kim Pate, and I live here on the unceded, unsurrendered territory of the Algonquin Anishinaabeg.
Senator Moodie: Rosemary Moodie, Ontario.
The Chair: Thank you, colleagues. Joining us today for our first panel, we welcome the following witnesses in person: From Métis Nation British Columbia, Colette Trudeau, Chief Executive Officer; and from the Canadian Indigenous Nurses Association, Ms. Marilee A. Nowgesic, Chief Executive Officer. Thank you for joining us today.
We will begin with opening remarks from Ms. Trudeau, followed by Ms. Nowgesic. You will each have five minutes for your opening statements, followed by questions.
Colette Trudeau, Chief Executive Officer, Métis Nation British Columbia: Tansi. Bon après-midi. Senators, my name is Colette Trudeau, and I am a proud citizen of Métis Nation British Columbia, or MNBC. Before I begin, I would like to acknowledge that we are on the unceded Algonquin Anishinaabeg territory, and I honour and respect their rights and title to these lands.
I am the Chief Executive Officer for Métis Nation British Columbia. I would like to thank the Standing Senate Committee for extending the invitation for us to be here this afternoon to speak to the pharmacare act.
Métis Nation British Columbia has over 27,000 registered Métis citizens, and we advocate on behalf of over 98,000 self‑identified Métis in the province. We have 39 chartered communities, and we are recognized by both the Government of British Columbia and the Government of Canada as the body that represents Métis in B.C.
The national definition of being Métis is a person who self‑identifies as Métis is distinct from other Aboriginal peoples, is of historic Métis Nation ancestry and is accepted by the Métis Nation.
Our citizens face significant health care challenges due to past and ongoing colonization, the impact of residential schools and discriminatory federal policies and practices. Excluded from the Non-Insured Health Benefits Program, many Métis struggle with the financial burden of health care. Most distressing, intergenerational trauma has created urgent mental health needs that are not adequately addressed, and Métis elders, seniors and those nearing the end of life lack culturally appropriate care, exacerbating their vulnerability.
Systematic structures of the provincial health care system do not reflect Métis’s lived experience, and this leads to exclusion and discrimination. Bill C-64, the pharmacare act, offers both opportunities and challenges to our Métis government. While it can address health care disparities, it also demands careful attention to Indigenous self-determination, data sovereignty and provincial cooperation. The Métis National Council estimates it would cost approximately $1.3 billion per year to enable Métis governments across Canada to fully self-determine the delivery of extended health benefits to our people who are responsive to their identified needs.
We do see strengths and opportunities in this bill. It will create equity in health care access. Bill C-64’s focus on universal access to essential medication, such as diabetes treatments, will address the high prevalence of diabetes among the Métis population and further address the disproportionate health challenges due to poverty and limited access to care.
It will also create collaborative governance. The Truth and Reconciliation Commission of Canada calls for the elimination of health disparities between Indigenous and non-Indigenous people. Universal pharmacare would support this goal by ensuring Métis people have equal access to medication, addressing one of the root causes of health inequity and contributing to reconciliation by addressing the Métis social determinants of health, which include poverty and access to health services. It also addresses Métis self-determination and cultural consideration. Bill C-64 presents an opportunity for Canada to respond to the health care needs of Métis.
The bill does present some challenges, however, ones that need consideration. Bill C-64 lacks provisions on Indigenous data sovereignty. While it mentions consultation, it fails to ensure Métis control over health data, perpetuating the erasure of Métis history and data. Data sovereignty is crucial for delivering culturally safe services.
The bill also has a narrow scope in the initial phase. Focusing on medications for diabetes and contraceptives is valuable but insufficient for Métis communities. High rates of chronic illness, mental health issues and limited primary care access require a broader range of pharmaceuticals to ensure the bill effectively improves health outcomes for Métis and all Canadians.
The bill’s success depends on sustained funding for pharmacare agreements with provinces. Without guaranteed funding and Métis governance, individuals in remote communities will continue to face resource shortages and health care delivery challenges. Long-term investment is crucial to ensure the program effectively reaches underserved Métis regions.
Beyond health outcomes, universal pharmacare would alleviate financial stress on Métis families who are more likely to experience income insecurity than non-Indigenous Canadians. We know from engagement with our citizenry, Métis are less likely to have health insurance to cover pharmaceutical costs. For those that do, a number of prescription drugs being offered over the counter are not covered by insurance.
Despite the challenges and considerations for Métis, this bill represents a step forward in the journey toward health self-determination. It will require ongoing engagement to ensure it fulfills the specific needs of Métis in a way that honours our rights and identity. We urge the Senate to take the following action to ensure Bill C-64 benefits all Métis citizens: Embed cultural safety in the pharmacare system to ensure it meets the unique needs of Métis, First Nations and Inuit; meaningfully collaborate and consult with Métis governments to ensure the implementation and delivery of national and universal pharmacare to provide culturally responsive services for Métis; and ensure the committee of experts convenes to make recommendations for operation of single-payer pharmacare, include a dedicated seat for First Nations representative, a Métis representative and an Inuit representative. All three Indigenous people —
The Chair: Thank you, Ms. Trudeau. We go on to the next speaker for five minutes.
Marilee A. Nowgesic, Chief Executive Officer, Canadian Indigenous Nurses Association: Good afternoon, aaniin, boozhoo.
[Ojibwe language spoken]
I am Marilee Nowgesic. I am originally from Thunder Bay, Fort William First Nation. I am of the Eagle Clan. I wish to acknowledge the ancestors of this region and thank you for participating today with them. I also recognize your ancestors at this table whom have come to bring us all here for a very important discussion.
I am the Chief Executive Officer with the Canadian Indigenous Nurses Association, or CINA, and we welcome this opportunity to speak about Bill C-64.
While the preliminary versions of this particular bill were delivered through federal, provincial and territorial governments and to the public to ensure timely access and information are distributed among the population, we also recognize that it was also distributed and discussed with multiple mainstream organizations, and we are hoping that Indigenous people, our partners, were included in those discussions. We are aware that Bill C-213 and Bill C-340 were delivered in the 43rd Parliament but never went beyond the first reading. We are very hopeful with Bill C-64.
We have concerns, though — much like my colleague — that the implementation of the bill may cause additional hardship, confusion, delays and administrative complications, which we don’t need, through existing health care systems managed by provincial and territorial governments.
In addition, there will be additional burdens placed on First Nations and Inuit who are already receiving program benefits under the Non-Insured Health Benefits program. There are also numerous issues that address the jurisdictional issues, residency, identifiers, geography and so on. The Indigenous nurses are the pivotal point of any community health care system. We are the voice of that pivotal point. These additional layers of bureaucracy will expand nurses already overwhelming work environment and existing scope of work. Please note that I said “nurses,” not only “Indigenous.” We look at all of our partners at this table.
The Canadian Indigenous Nurses Association is the longest-standing Indigenous health organization in the country with a 50‑year history. We have engaged in an extensive community-based, regional, national and international activities related to health human resources, our members’ support, consultation including regulatory and legislative affairs like this one, policy, research and education. CINA, as we are otherwise known, has and continues to have a history of successful collaboration with numerous Indigenous health and leadership organizations, mainstream nursing organizations, educational institutions, federal-provincial-territorial government and local Indigenous government. We have also maintained our liaison with the national organizations representing First Nations, Métis and Inuit people. It is through their health portfolios that we bring information like this to their committees.
Of particular importance today is our network with the Indigenous Pharmacy Professionals of Canada, which is a non‑profit, member-based organization that serves to cultivate a thriving and empowering community of Indigenous pharmacy professionals, to support safe and equitable care patients, families and their communities. They are a part of our growing network and one that we are looking forward to working with.
The work related to accessibility and affordability through this bill and the appropriate use of prescription drugs needs to be accomplished together with pharmacare partners. We are looking at the pharmacies as well as the corporate sector and their corporate social responsibility, with the goal of designing, developing and implementing a national universal pharmacare. The participation of CINA will help to address the priorities of patient safety and address better health outcomes and maintain the accountability of the health care system.
The engagement of CINA members, as I provided in a report here, is one that we have a voice of approximately 10,000 nurses across the country. This study was done with the University of Saskatchewan in 2018. However, since that time — and many of you are aware of this — the use of identifiers has become problematic. We, therefore, cannot safely say what that number would look like.
In 2021, almost a half a million nurses were identified through the Canadian Nurses Association. That is a strong number. Again, we do not know what those Indigenous numbers may mean within there. People are reluctant to identify within that profession for many reasons you have heard about. We do know that at least 3,000 of those are Registered Nurses, or RNs, 7,500 of them are nurse practitioners, 130 are Licensed Practical Nurses, or LPNs and 6,300 are Registered Psychiatric Nurses, RPNs. That’s a lot of nurses to bring to the table to discuss pharmacare. But we feel that through CINA we can provide that voice to all of the nurses and our allies and partners.
With financially supported coordination, we know that we will be able to bring forward the technical and expert advice for clinical tracking; the various plans and prescriptions that are being covered; the collection and analysis, like my colleague pointed out, of data; and the sovereignty of that data to our people. That we help you identify improvements to be made to the pharmacare system that may include items such as the national formulary, geographical considerations such as access to the medication based on their residency. It is one thing to come out of the hospital and tell your patient, here are your discharge requirements. But where are they going to go if they can’t get to the pharmacies? Thank you.
The Chair: I’m sorry to cut you off but we have a lot of senators in the room and lots of questions.
Colleagues, we will proceed in this way. Every member who has a question will be given three minutes. Priority will be given to the members of the committee, and we will then get to visiting senators after that.
Senator Osler: Thank you to both witnesses for being here today. My question is for both of you. It is a two-parter. Perhaps I’ll start with CINA.
Does Bill C-64 address socioeconomic barriers and gaps in pharmacare coverage for Métis peoples and First Nations and Inuit individuals who are not covered under the Non-Insured Health Benefits program? Second part: Could Bill C-64 erode access or coverage under the Non-Insured Health Benefits program?
Ms. Nowgesic: Senator, can I have the first part of your question again, please?
Senator Osler: Does Bill C-64 address socioeconomic barriers and gaps in pharmacare coverage for Métis peoples and those individuals not covered under the Non-Insured Health Benefits program? On the flip side to the question, could Bill C-64 erode coverage in that program?
Ms. Trudeau: I can start with the first part of that question because the second part is to my colleague.
It is absolutely a start. As I mentioned in my testimony, to meet the needs of Métis people, we would need about $1.3 billion in our province to address those socioeconomic gaps that you speak to. With the phased approach that has been shared; it addresses some of the need but not all of the need. I will say that Métis people, in our province, come to their Métis government for services and supports, and we have been limited in what we can do to support our citizens. This is a way for us to start addressing some of those gaps due to the socioeconomic gaps that our Métis citizens experience, but it is just a start. It won’t anywhere meet the need of our citizens.
Ms. Nowgesic: The gaps are significant. Will it address the gaps? No, because we have not had ample opportunity to be able to bring together the Indigenous partners to the table to bring forward their numbers and be able to testify that these are the numbers that resonate with the picture of their people’s dynamics.
Therefore, yes, it would impact on those who covered who are not part of or not qualified to participate in a pharmacare program. It causes significant barriers and missed opportunity. It erodes the coverage. From the nurse’s lens, and that’s what I’m trying to look at this from, we need access to live, real-time formularies. We need exemption codes. We are having experiences where pharmacists are taking ownership and changing the discharge requirements or prescriptions being provided because they feel that patient safety is an issue.
We’re trying to look at how this system addresses the needs of the people in real time. It is one thing to be sitting here, where you can run to a pharmacy. It is another thing where bureaucracy takes over. Forty seconds of your time is a lot.
Senator Moodie: Thank you to the witnesses for being here today. I want to ask a question that has been asked before because I want some clarification in a simplistic way. Diabetes disproportionately impacts Indigenous people and communities. Higher rates of diabetes occur, higher incidence of chronic illness and complications as bad as even death. Co-existing conditions requiring medications and interventions, increasing cost, burden of health for communities: all of this is true.
If a pharmacare system that comes out of this legislation allows every individual to walk into a pharmacy, present themselves and ask for their medication, and they get it free of co-pays, dispensing fees — it is handed to them free of cost — does that improve the outcome of your people?
Ms. Trudeau: I’ll start by saying in theory, yes, it does. However, we have stories of folks who are in remote communities that can’t just head to a pharmacy to get their medication. In addition to that, in northern B.C., there is a community called Kelly Lake, and we have heard a number of stories wherein just leaving the community to access any type of health care often results in folks passing away because they do not feel safe accessing those programs. When we’re talking about just meeting a basic need of being able to walk in and get your medication free of cost, that’s fantastic, but there are other barriers in play that need to be addressed for Indigenous people — and I speak on behalf of our Métis citizens in B.C. — for Métis citizens to feel safe going and accessing. That’s why we think that ensuring those voices are on an expert committee and that there is culturally safe access are important points for Indigenous people to be able to access the pharmacare program and for the program itself to be successful.
Ms. Nowgesic: Thank you for the question. In simplistic terms, I wish we didn’t have to go to the pharmacy to be treating these. Then we wouldn’t need the discussion in regard to chronic conditions.
But as we are addressing them, it does impact on the level of the burden and increases the burden on what the treatment is.
The additional requirements that we as Indigenous nurses face are the implications of traditional approaches that are being administered in lieu of missing medications and/or therapies that are being provided to our Indigenous people. That has been long‑standing. Our people are not telling the providers that they are still using traditional medicine, so it impacts the conditions. However, it does help them to treat and eliminate and have better outcomes.
The Chair: Thank you, Ms. Nowgesic.
Colleagues, we have a scant 20 minutes.
You are giving us great wisdom, but I am challenged with trying to ensure that my colleagues get all their questions in.
Senator Pate: You certainly have a great deal of expertise and experience in this area. The minister has reiterated to this committee, in response to potential concerns from First Nations and Inuit people, that Bill C-64 would not affect access to the Non-Insured Health Benefits program, which would continue to be available on its existing terms.
Given that, do you have suggestions about how the federal government can effectively share information about continued access to the NIHB program to reassure users or communities who may be concerned about the impact of Bill C-64 on their existing benefits?
Ms. Nowgesic: Thank you for the question. It was two of the points that were in my recommendations. One is the allowance for Indigenous leadership to establish timelines that resonate with their community people and be able to address their issues and perspectives; that the collaboration with ongoing funding to support Indigenous health care provider organizations like CINA to design, develop and implement an arm’s-length structure to oversee an evidence-based policy, research and education structure and pharmacare. There is much that still needs to be learned by this industry about our people.
I am surprised — the effectiveness of health care, because that is just like Pandora’s box. They come in. “I lost my ID.” They are not in the system. You have multiple names. You have the same family last name. I have over 100 relatives with the name Nowgesic spelled 26 ways. Thank God we have birthdays; I don’t think we share the same birthdays. But that access, how do we formulate, track and monitor it, especially when we’re looking at substance abuse, opioid crisis and management of chronic conditions?
Senator Bernard: Thank you both for being here. I have changed the question I wanted to ask based on some of your responses. Ms. Trudeau, I think you used the term “culturally safe access,” and I think you were speaking about that but not using the language. It would be helpful for us to know what you mean by “culturally safe access.”
Ms. Trudeau: Thank you for your question. In the context of Métis, we are often referred to as the “forgotten people.” When we’re talking about the Indigenous context, we’re not considering the distinct culture, language and history of Métis people. Even when we see “Indigenous,” that doesn’t always mean that Métis people are included or seen. When I talk about culturally safe, I’m talking about visibility, seeing Métis, which is a similar piece of advice I have provided to the Senate before: When we’re talking about Indigenous, say “Métis,” so Métis people know that is a program or service that is meant for them.
Visibility, belonging — it changes the way that a Métis person feels when accessing a program. When I say “culturally safe,” it is talking about those values, that visibility, so that Métis people know that they are comfortable and visible in that space. It’s working with elders, knowledge keepers and our communities to ensure that that is true.
Ms. Nowgesic: To provide you with context, cultural safety, when we’re responding to it now, is cultural safety and humility. It’s that entire exercise that needs to be ingrained into all the health professions — one that we have successfully been able to do with the nursing schools across the country.
At the same time, people are getting confused with cultural safety and cultural competence. The competence and the ability to be able to say, when someone presents at the clinic or into the ER and to surgery, and they have a medicine bag on their chest, who are you to take it off of them? Who are you to remove it? That is part of their being.
When we’re looking at this, that needs to be ingrained as part of what that pharmacare system is going to look at and how we, as CINA, with the number of years we have — not only do we have knowledge holders and elders, we also have medicine people and those people who are integrated into their environment, knowing what is going to work for you in your region — what is going to work for my Ojibwe people is not going to work for the Mi’kmaq people; we come from two different areas.
[Translation]
Senator Mégie: Following up on Senator Bernard’s question, you talked about cultural safety and humility. You also mentioned that these are obstacles when Métis people go to the pharmacy to get their medication themselves. Would it be possible to discuss these issues in talks between the federal government and the provinces and territories? Are there people in the various communities you could reach out to during discussions to make them aware of such issues? Otherwise, everything will remain vague and get codified as it is for everyone else. Is there any way you could do this with your people, that is, include these issues in your discussions?
[English]
Ms. Nowgesic: What we’re looking at is how we get the information. Your understanding of it is one thing; how do we make the application into reality? How do we ensure that the information of what is intended is being provided to the Indigenous leaders, the health care providers and to the people? There has been no discussion on how this is going to unfold, and yet the Indigenous people sit there and think, “Oh, no, they’re going to monkey around with our stuff again. What is going to happen now? I’m going to get lost.” They will wonder what will happen to their condition. Then we look at how quickly we are able to respond in an environment of rapidly depleting health care providers. Thank you.
Senator Burey: Good morning again, and thank you so much for your expert testimony.
I’m a physician, and I remember the days — this is dating me now — when, depending upon a patient’s circumstances, they could get a whole prescription when they left the hospital. Now that doesn’t exist. That talks to some of the things.
Just hearing your testimony, this is a first step. I’m hearing that you’re in favour of this bill as a first step, but it’s a larger issue in terms of Indigenous sovereignty over themselves, how health care is delivered, and how their data is guarded and issues of data sovereignty.
But I wanted to home in on questions on implementation, because people are listening to the testimonies here to understand the barriers. As we know, the devil is in the details — implementation, the confusion, the administrative burden as a service provider — you know that as well as I do.
What could you say to help us along that way? What do we need to do or hear today?
Ms. Nowgesic: You need to allow us the time to provide the engagement, discussion and development of a framework toward a strategy that will address each of those items.
As you’re well aware, as a physician, those things have changed drastically over the decades, much like some of the terminology of the conditions that the people deal with. Social workers are now being called navigators, so people do not even recognize the social work designation; they’re calling them navigators. Physicians only come to the communities when they become available. Imagine if you could only see one every second or third month. It is our nurses who are there day in and day out, 24/7, and who could help lead.
What would that framework look like? Like you said, the devil is in the details. What would that design look like, based upon Indigenous indicators, Indigenous methodology and Indigenous frameworks? Those are new. What are the ethics behind that Indigenous research? There is education that goes along with it.
Just because you’re looking for something in the fall of your fiscal year, does not mean that all of our Indigenous people are available. A great example of that is trying to get them to the election polls. They’re out hunting and trapping, collecting their medicines and looking at their harvests. If we could do that, then we could track and work much more closely with health care providers and with traditional medicine people to determine where it is still alive or where it is damaged; this particular product no longer exists.
We would also look at resistance. The levels of resistance are getting higher — the numbers of medications. Where are they supposed to go when it doesn’t work? How are they supposed to go, and how are they supposed to access it?
Ms. Trudeau: On the engagement piece, it’s about ensuring there’s adequate time to engage communities to receive that feedback and, following the engagements, ensure that the feedback is actually included in the path forward. We have participated in so many consultation engagement opportunities and provided feedback, and still there is no Métis perspective to be found.
So, ensure the various nations are demonstrated within the final report
Senator Quinn: Thank you for being here, folks. I’m going to build upon a topic of Senator Osler’s, I think. I want to briefly ask about the Non-Insured Health Benefits, what is currently covered and what is being looked at in Bill C-64 at this stage.
Yes, it’s a first step, but wouldn’t it be beneficial to have things going on as a first step at the same level? Isn’t that something we should be considering — to cause it to be at the same level so we can get into the further consultations and discussion?
Ms. Trudeau: On the non-insured, it’s important that I just reiterate that Métis people are not included in that. So getting that to par, absolutely — but know that Métis are starting from a very different starting place than First Nations.
Ms. Nowgesic: Addressing that into your — that would be nice, going with Bill C-64 and NIHB at the same time. It will never happen because we keep changing the conditions or game rules — the playing field — and when you keep changing those conditions, it causes mass confusion among health care providers, never mind the recipients.
With that in mind, that’s why CINA feels that if we could design what that structure would look like. Senator Quinn, I understand what you’re trying to get to, but that’s the exact thing that we are saying: If you don’t have leverage on the playing field — we don’t have a sense of “here is what you want as far as indicators” and what you have as far as Non-Insured Health Benefits. When it rolls out in reality, there are all kinds of hoops and jumps and barriers to be addressed during that time, conditions like, “Oh, you can’t do that, or you’ve already qualified for it, or you’ve overspent.”
If Bill C-64 can eliminate some of that, the people would be there in a flash, but the Non-Insured Health Benefits program provides an additional bureaucratic limitation to the people, let alone the health care providers who are trying to do this. Bill C-64, then, in essence of the Indigenous people — because what we’re saying is we never negotiated. We never gave up our inherent right to medical treatment under the Treaty 6 clause. Thank you, Alberta. We never gave that up. We’re not here to negotiate it.
What we will say is that we are here to find a way with you to make it better for all of us in the long run. Data collection will be an integral part, but data collection on our terms and stored by our people. We will be the stewards of where it goes, when it goes and how it goes.
Thank you.
The Chair: Ms. Trudeau, Ms. Nowgesic, thank you so much. You have given us a great deal to reflect and chew on.
We welcome the following witnesses joining us by video conference: the Honourable Adriana LaGrange, Minister of Health with the Government of Alberta, and the Honourable John Main, Minister of Health with the Government of Nunavut. Thank you for joining us today. We will begin with opening statements from Minister LaGrange followed by Minister Main.
Minister LaGrange, the floor is yours. Five minutes, please.
The Honourable Adriana LaGrange, MLA, Minister of Health, Government of Alberta: Thank you very much. Good afternoon, senators and guests. Thank you for this opportunity to speak with you today about Bill C-64, An Act respecting pharmacare.
I will briefly share some of Alberta’s concerns and what information and approach we in Alberta need to be able to move forward.
The federal government continues to bring forward health initiatives as a way of pursuing its own political goals when its actual responsibility is to act as a good partner in the long-term sustainability of health initiatives and improved health outcomes. Provinces and territories have exclusive jurisdiction over the planning, organization and management of our health care systems. Alberta’s government recognizes that there are indeed nationwide concerns regarding gaps and direct coverage, and the sustainability of direct public programs. I believe, on this, we do agree, and we would like to work further toward tangible solutions.
However, the federal government chose not to consult with Alberta on a national pharmacare scheme prior to tabling Bill C-64. There have not been any significance consultations since. The government of Alberta makes decisions about its health care system to serve the needs of all Albertans best, not to serve federal agendas. The federal government must respect provincial and territorial jurisdiction and the decisions we make. Federal initiatives, such as pharmacare, must be developed in a way that is truly collaborative, aligns with provincial and territorial priorities, and respects jurisdictions.
Making drugs more affordable and accessible to individual Albertans is very important to Alberta’s government. We have some of the most comprehensive public drug programs in the country, covering over 5,000 drugs, and we intend to maintain our current benefit offerings. The federal government can assist us in enhancing our current offerings by not adding duplicate programs or creating unnecessary and costly administrative burdens. It is also unnecessary for the federal government to provide coverage for pharmaceuticals that are already funded by existing provincial health benefit plans.
It does not serve Albertans for the federal government to offer them fewer pharmaceuticals than they currently access under Alberta’s more expansive formulary. For example, the federal diabetes medication list doesn’t include some of the newer, more expensive drug therapies that align with current clinical practice guidelines, such as Ozempic and certain newer, more effective insulin options. Many of these prescription drugs are currently listed in Alberta’s formulary.
It’s easy to foresee that the exclusion of these newer therapies could result in affordability and equity concerns, and risks for diabetes patients and our province.
Alberta is concerned about the rapid pace of the targets set out in this particular piece of legislation, and if the federal government is really sincere about making progress on their plans and promises, they need to provide far more details on the cost implications for recipients and provinces, the timing, the national drug list, the national bulk-buying strategy, and other risks and cost implications.
Albertans value choice and the proposed pharmacare program will limit that choice.
Those are just a few of Alberta’s concerns regarding the implementation of Bill C-64. Alberta is very willing to work with and discuss ways that the federal government can invest in Alberta’s existing comprehensive pharmacare programs and help us expand coverage to those who need it the most. We should have the right and the opportunity to utilize Alberta’s taxpayer-supported federal funding that represents Alberta’s fair share to enhance our existing programs and health initiatives, particularly for those who are the most vulnerable.
Alberta will continue to call on the federal government to provide predictable, sustainable, unconditional health funding to the provinces and territories.
I once again thank you for this opportunity to speak, and I look forward to your questions.
The Chair: Thank you very much, Minister La Grange.
Minister Main, please go ahead.
The Honourable John Main, MLA, Minister of Health, Government of Nunavut: I’d like to thank the Standing Committee on Social Affairs, Science and Technology for the opportunity to speak today about the potential impacts of Bill C-64, An Act respecting pharmacare in Nunavut.
First, I would like to share some information with the committee members on Nunavut’s health care system. We provide care to approximately 40,000 residents across 25 communities. These communities are divided into three regions and three time zones; Nunavut covers one fifth of Canada’s total landmass. Our main health care facilities are our 35-bed hospital in Iqaluit, 2 regional health care centres in Cambridge Bay and Rankin Inlet, and 22 health centres in other communities. We also have 1 mental health facility and 5 long-term-care facilities in the territory.
Our geography and travel logistics have shaped health care in Nunavut. Long distances between communities and a lack of a road system necessitates our having health centres in every community, where outpatient and 24-hour emergency nursing services are provided. We rely heavily on medical travel to Southern jurisdictions like Alberta for specialized and emergent care needs.
In fiscal year 2023-24, health arranged over 49,900 scheduled airline tickets and over 2,500 medical evacuations for Nunavummiut at a cost exceeding $121 million. Due to our geography and our lack of in-territory capacity, we have the highest level of spending, per capita, on health care services at $21,000 per person compared to a national average of $8,500.
We rely heavily on federal investments and agreements to work toward health equity across the territory. We welcome any federal efforts to increase equitable access to health care across Canada.
Several key health indicators reflect the challenges impacting Nunavut Inuit in the territory. We see lower-than-average life expectancy, a higher infant mortality rate, higher numbers of youth suicides and a significantly higher rate of tuberculosis. We’re also seeing an upward trend in chronic illnesses, such as diabetes, chronic obstructive pulmonary disease and hypertension.
Discussions about increased access to care in Nunavut must be considered in the context of social determinants of health, and we must also consider the impacts of colonialism on Northern communities and what reconciliation looks like.
Nunavut health care is publicly funded, with most essential services covered through the Nunavut Health Care Plan. This plan covers doctor visits and consultations, and hospital services including diagnostic tests, surgeries and medically necessary procedures. Close to 85% of Nunavut’s population is Inuit. As such, most of the population is covered through the NIHB program, from Indigenous Services Canada. The Non-Insured Health Benefits program includes coverage for prescription drugs, medical supplies and equipment, dental, vision care, medical transportation in and out of the territory, and mental health services. Therefore, only a small proportion of Nunavummiut, roughly 15%, are not covered by NIHB. However, about half of those people work for the territorial and federal governments and are covered by employer health care benefits.
The demographic landscape in Nunavut makes the impacts of Bill C-64 unique among the other provinces and territories. While the introduction of Bill C-64 would ensure all Nunavummiut have access to free diabetes medication and oral contraceptives, they are a small number of Nunavummiut who aren’t already covered under either NIHB or employer benefits.
There are certain aspects of this program that would require clarification to ensure its effective implementation in the territory. First, as noted above, while Nunavut has 25 communities, we only have only seven retail pharmacy, with three of those being in Iqaluit. The other four are in the communities of Rankin Inlet, Cambridge Bay, Arviat and Baker Lake. The ability of Nunavummiut to obtain these eligible medications through community health centre pharmacies without a retail prescription as part of the pharmacare program is not known at this time.
Second, with the majority of Nunavut’s population receiving health care benefits through NIHB, including medications, it’s unclear how this program will interact with NIHB under Indigenous Services Canada. Based on an assessment of Health Canada’s proposed list of diabetes and contraceptive medications, the NIHB program formulary already meets the standard for coverage proposed in Bill C-64 with respect to the list of drugs and the level of coverage. In other words, there are no co-pays or deductibles.
It’s unclear what impact this proposed approach will have on NIHB-eligible clients who are currently fully or partially covered by private payers. This is an area where we will need to work with our federal partners to identify and resolve any issues.
Finally, the impact on employee benefit programs needs to be determined. As an employer, the Government of Nunavut and its employees pay insurance premiums so that private insurance providers will pay for diabetes drugs and oral contraceptives. With the introduction of Bill C-64, they will no longer be required to pay for these drugs that are typically taken daily and are generally used long-term and for which the insurance company incurs high costs. Removing these drugs from private insurance claims could potentially lower the overall cost of employer health benefits for the Government of Nunavut.
While we have identified some challenges to work through in the administration of Bill C-64, we welcome further discussions with the federal government to understand the interactions with the NIHB, to ensure Nunavut Inuit receive the best access to care. We are not opposed to federal supports in the field of health care and already work collaboratively with our partners to strengthen health care in Nunavut.
I have a couple of specific points to end off with. Approximately 6% of our residents are pre-diabetic or living with diabetes. We know the associated health risks are serious, and having access to diabetes medication at no cost to the individual can be life-changing and even life-saving.
In addition, offering free oral contraceptives promotes reproductive health, empowers individuals and can lead to better social and economic outcomes for entire communities. It prevents the health risks associated with unplanned pregnancies as well as the financial implications. Planned pregnancies are associated with better prenatal care and healthier outcomes.
The Chair: Minister, I am fascinated by your testimony, but the clerk tells me we are going to be very short of time.
Senator Osler: Thank you to both ministers for being here today. My question is for Minister LaGrange.
In his recent clarifying letter on Bill C-64, Minister Holland specified that the cost of medications would be paid for and administered through the public plan.
Now, Alberta is known for exploring different models of health care delivery, for example, a new one-stop health campus in Airdrie, Alberta. Minister, you voiced concerns that a national pharmacare program would increase the bureaucracy and administrative burden on a province.
Should provinces look to Alberta for different models of health care or pharmacare delivery — possibly even models that explore public-private partnerships — beyond the claims processing that your government currently uses with Alberta Blue Cross?
Ms. LaGrange: Thank you for the question.
First and foremost, we absolutely believe in publicly funded health care, and we have worked very hard to be innovative and make sure that our citizens of Alberta get the absolute best health care available to them. I know that many concerns have been raised, not just by ourselves — by our province — but many other provinces as well and by many other organizations, such as the Canadian Life & Health Insurance Association, McKesson Canada, and the Canadian Generic Pharmaceutical Association, just to name a few.
The issues really revolve around disrupting existing prescription drug coverage that is paid for by employees, limiting choice for Canadians and Albertans, using scarce federal fiscal resources to replace existing coverage, and failing to provide coverage for uninsured Canadians who rely on other medications beyond a short list of these particular drugs that really only address two health issues when we have a myriad of health issues in our province.
In Alberta, we are very proud of the fact that our pharmacists have the largest scope anywhere in Canada. They actually work to full scope and beyond in the sense that they are able to have clinics. They actually have clinics that citizens can go to. It expands our reach into our northern and remote communities where we don’t have access to physicians.
Minister Main expressed very eloquently the issues of rural and remote communities, and using an expanded pharmaceutical scope that we have here in Alberta that has proven itself to be very safe and effective and has enhanced the overall experience for Albertans.
Hopefully, that answers your question.
Senator Osler: Thank you, minister.
Senator Pate: In the interests of time, I’m going to ask both my questions — one for each minister — and then if we run out of time, perhaps you could answer in writing.
Minister Main, I recall your work a number of years ago in support of a guaranteed liveable basic income for Nunavut, and we know that income is the number one social determinant of health. What steps could the federal government take while implementing Bill C-64, both in its short-term steps of diabetes and contraceptive coverage and its long-term progress toward a national single-payer system, in order to redress income and health inequalities?
Minister LaGrange, the Canadian Medical Association Journal has found that Alberta’s system has resulted in the highest out-of-pocket costs in Canada for people with low incomes. I’m curious whether you see some way that the Government of Alberta is going to redress this and whether you would agree that this is a significant cost barrier for individuals with low incomes?
If we could start with Minister Main, please, and then Minister LaGrange.
Mr. Main: Thank you for the question.
In terms of the social determinants of health, it is a huge factor in everything we do in health care in Nunavut. Obviously, we’re focused on the nuts and bolts of the health care system with staffing being our main challenge. Infrastructure is another huge challenge. Fiscal sustainability is right up there as well.
In terms of the social determinants of health that are really impacting people on a daily basis, we’re talking about food insecurity, and we’re talking about housing. Other issues are the impacts of colonialism and intergenerational trauma.
In terms of what the federal government can do, we need to better understand the return on investment when it comes to investing in things like food security. Indigenous Services Canada has recently expanded food security supports through the Inuit Child First Initiative in Nunavut, and there are a number of communities across the territory that are handing out vouchers — for lack of a better term — to families with children. This is a very new initiative where we have thousands of children across Nunavut who are now getting these supports toward food security, specifically healthy food.
One thing we would like to understand better is what the impacts of that outlay are. It is incredible to see the impacts in our communities when you speak to parents and families. Anecdotally, we have evidence that it is having a very positive impact.
In terms of health indicators, what is the positive impact? Can we measure it? My desire would be to see food security supports increased and continue, like under the Inuit Child First Initiative that is currently running.
Thank you.
The Chair: Your question to Minister LaGrange will have to wait, Senator Pate.
Senator Moodie: My question is to Minister Main.
One of the particular requirements and geographically significant issues that you face in Nunavut is the fact that you must maintain a higher inventory level of medication than most other jurisdictions in Canada. Alongside that would be where those medications are not used, there is an increased level of waste and financial burden to your region and to the health care system in general.
In your opinion, is there anything the government can or should do to address prescription inventory in Nunavut? As you go into these discussions with the government, what would you like to see from the negotiations with the government in relation to the agreement set out for pharmacare, for Nunavut?
Mr. Main: Thanks for the question, and you hit on a couple of important notes there, so thanks for the opportunity. In terms of managing inventories, one thing that we do need — it’s on our wish list, as a territory, and it is something we are building toward — is a public health information system. Currently, we’re without the proper information technology infrastructure to manage — to have a real-time tracking of things like vaccine inventories. In terms of the public health side, that’s a definite need, and it would, I believe, help us to manage inventories of things like vaccines. We are also building out our health information unit within the department, which is something that has been done with supports from federal funding agreements in the past, and we continue to expand our capabilities there.
In terms of what we would be looking for from our federal partners, it is always the need for flexibility and the need for recognition that Nunavut is a unique jurisdiction, as I outlined in my remarks. We have always said at the federal-provincial-territorial tables, per capita funding arrangements do not work in Nunavut. You just have to look at the logistics of trying to get a person who is in medical distress from Grise Fiord down to Ottawa, and you are talking tens of thousands of dollars. I’m not saying that it is not necessary or that it is a waste of money. It is just that is so much more money than it would be to go from your house to a hospital in a major city in Canada. So we are entirely unique in that sense, and we would be looking for flexibility and support from our federal partners that goes beyond just the operations of our health care system. We are increasingly looking for support when it comes to health infrastructure.
[Translation]
Senator Mégie: Good afternoon, ministers. I am going to ask my questions in French. I know that, usually in life, there are many topics that you discuss among the provinces, and the same is true for separate provincial-federal talks. If Bill C-64 were adopted as is, taking into account that Nunavut is unique and considering the various points raised by Minister LaGrange regarding Alberta, couldn’t these elements be discussed in your provincial-federal talks so that you could ask for the flexibility you need? Could you discuss these topics at these different times? This question is for each of you.
[English]
Ms. LaGrange: I’m happy to address that first and then turn my time over to Minister Main.
Certainly, we have examples where there has been a good consultation with the federal government, and I think to the recent agreements that I have been able to sign — the bilateral agreements on the shared priorities, Aging with Dignity, and we’re very close on the rare disease drugs. But what I fail to understand is why this particular bill did not go through that same process, why the consultation process did not happen before this bill coming forward. From our perspective, those consultations should have happened before we got to this point, because we are all very unique, and of course, as I indicated earlier, it is provincial jurisdiction. Health is provincial jurisdiction. We have very unique areas that we are looking to address, and as I indicated, in Alberta, we are quite fortunate. We do cover a lot of drugs already, and we would look to enhance the programs that already exist.
I’m concerned about the fact that not only are there a number of drugs that are not covered, but there are also older devices that are proposed to be used, and all of this consultation could have saved a lot of the consternation that we’re seeing happening right now. I’ll turn my time over to Minister Main.
Mr. Main: Thanks. I think it is a really good question, and it is a really interesting one. Essentially, it boils down to trust, in my role as Minister of Health for Nunavut, what trust or relationship do I have with my federal partners, and when I look at the recent work we have been able to do on the bilateral agreements — the Working Together bilateral agreements, including Aging with Dignity, and we have also done recent work on Non-Insured Health Benefits funding with Minister Hajdu. I can say that from Nunavut’s perspective, we do have a good, productive relationship. There is trust. I am comfortable with the level of ambiguity within the legislation as it is currently proposed and that we can work things out with our federal partners. It doesn’t necessarily need to be every last detail included in the legislation. Thank you.
Senator Dasko: My question is directed to Minister LaGrange. Your nonparticipation in the program will mean — and since the federal bill doesn’t offer compensation to provinces who do not participate, it means that there are federal dollars that are being left on the table. Do you think Albertans might be unhappy that they won’t have access to these federal dollars? That’s my question. Thank you.
Ms. LaGrange: Well, thank you for the question. First and foremost, I believe that Alberta — as a contributor to the great country of Canada through our ongoing funds, tax dollars, et cetera — contributes something that is of value to the country of Canada, and we should be treated fairly. To be treated fairly means that we should get our fair share of whatever dollars are provided through this pharmacare program. Our position would be that as having exclusive jurisdiction in health, we should, in fact, have whatever is fairly owed to the Province of Alberta to administer to the citizens of Alberta.
My understanding, having spoken with Minister Holland, is that there is a desire for consultation, and while we regret it has not happened prior to this bill being put forward, my understanding is that there is still room for discussion. So I would like to see that discussion happen. I would like to see the ability of Alberta to retain the current programs that it has to ensure that Albertans do have choice and retain choice and that we get our fair share of whatever is put forward through this pharmacare bill and that we would be able to administer it to enhance the current programs we already offer. That would be my expectation.
Senator Dasko: Thank you very much. I read from your comments that you are willing to go further with the federal government than what I interpreted from your opening comment. So you are wanting to engage with them in a discussion about —
Ms. LaGrange: We are always wanting to engage with the federal government, but we always retain the right to opt out of federal programs that actually go into areas of provincial jurisdiction.
Senator Dasko: Yes, of course.
Ms. LaGrange: So I have to be very clear on that. We do feel this is a provincial jurisdiction. We don’t feel that we have the engagement nor the consultation that was due to our province prior to this bill coming forward, and we retain the right to opt out.
Senator Dasko: For example, the Province of British Columbia is now in discussions with the federal government with respect to this program and with respect to the medications that will be covered. Would you envision that you would be engaged in the same way?
Ms. LaGrange: Well, I would like to see what comes forward. As I said, we have had some successful bilateral discussions over the last while and successful agreements on the shared priorities and Aging with Dignity, and we’re very close on the rare disease drugs.
On this one in particular, there was no consultation previous to the bill coming forward, so it is taking a different tack. There are a lot of unknowns and ambiguity, and for us to support something with a lot of unknowns is difficult.
I will look forward to getting more information from the federal government and from Minister Holland and his ministry as time goes on, should this bill be successful.
The Chair: Minister LaGrange, I have a question of clarification. I’m not an Albertan, but I do appreciate all that Alberta brings to our nation.
Are the two listed drugs for diabetes and contraception — drugs and devices — are they currently covered for Albertans? If so, to what extent?
Ms. LaGrange: The vast majority are, and I can get you a list of the ones that are covered and the ones not covered. What we are seeing, as we did our analysis, is that, in fact, a lot of the drugs are older drugs, not necessarily the newer drugs or the ones currently being used and are the most recent therapeutics being used. The same applies to the devices. That’s my understanding as well.
To answer a previous senator’s question, I’m proud of the fact that in Alberta we look after our most vulnerable, and we have some comprehensive programs that offer drugs and services to our most vulnerable seniors and low-income individuals, and our analysis showed that in the way the program is currently listed to be brought forward there are approximately 100,000 low‑income, vulnerable Albertans who would not qualify, and that’s very concerning to me and to the citizens of Alberta.
The Chair: Thank you, Minister LaGrange.
Senator Miville-Dechêne: I want to follow up on my colleague’s question. You have some of the same arguments as Quebec in terms of not meddling with provincial jurisdiction. However, if Albertans are now getting drugs for diabetes and for contraception, are they getting them for free? Do you have programs that give them for free? Or do they have what we call — I think it is the same thing in English — franchises that people have to pay for them? It is the case in Quebec. Can you make a comparison?
I’m a little surprised by the fact that the federal program would cover fewer vulnerable people because it is free for everybody. I’m trying to understand what you fear here.
But, first, are those two classes of drugs available for free in Alberta?
Ms. LaGrange: First, again, I would like to say that these two areas that the federal government is looking to provide pharmacare for, they are just two of a myriad. To call it universal pharmacare is not accurate.
Second, on the drugs that are currently being supplied to our low-income and vulnerable, we have everything from zero pay. For those with employee plans, there are other payment options available, et cetera. But we have very comprehensive drug coverage in Alberta with a range depending on your level of income and your ability to pay. There is a lot of range.
Again, what is threatened by this bill, as it is currently written, is the loss of the ability to have choice within Alberta. In fact, as I already indicated, there are listings on this particular bill on diabetes for older medication and devices that people don’t use nor do they want to use. Why would the federal government be covering devices and older medication that nobody is using? Why are they not listing newer medications? Perhaps that’s a discussion that will happen. For us, there are many questions.
As I indicated, when we did our research, there are roughly 100,000 people who wouldn’t even qualify. Again, what is the purpose? Why are we duplicating services that exist in Alberta?
Senator Miville-Dechêne: How do you arrive at 100,000 vulnerable people that would not qualify, considering — I’m not saying it is universal — those two classes of drugs are free? You say you have people who work and who have modest revenues, but I’m pretty sure they have to pay a franchise. How do you calculate the 100,000 vulnerable people who would be negatively impacted by Bill C-64?
Ms. LaGrange: Well, that was a review done by my department to look at the impacts of Bill C-64. As it currently exists, as we understand it with the limited information and the lack of consultation we have had during the process, this is what they were able to determine and share with me.
There is, again, opportunity for us to have further discussions on this, but at this point, there are health care programs available to Albertans and other Canadians. As I indicated earlier, the Canadian Life and Health Insurance Association, McKesson and the Canadian Generic Pharmaceutical Association have expressed concerns because they have programs in place that currently offer more than what this limited offering will offer to Albertans and to Canadians.
There is also a concern about fiscal sustainability. When we look at the limited resources that the federal government has and the expansion of need across this province and the country, we know that to duplicate programs that already exist, it seems like more thought should be going into that.
I know the federal government has federal jurisdiction over the First Nations, and I constantly hear from our First Nations that there is a lack there.
The Chair: Thank you, Minister LaGrange. We are around the table a tad confused about your statement that 100,000 Albertans would be less better off. If you can share any materials where that number comes from, we would welcome that.
We have another panel this afternoon with, I believe, life insurance companies, so we can probe them as well.
Colleagues, sorry for rushing you, but our time is over. Thank you to the two ministers for attending and enlightening us with your regional and provincial perspectives. Those are important to remember.
Colleagues, I want to remind us that we are back to study Bill C-64 in our usual place at 4:15 p.m., and, as usual, because tomorrow we go to clause by clause, if you intend to propose amendments or observations tomorrow, please share them with the clerk in advance in both official languages.
(The committee adjourned.)