1 DATE: October 1, 2024 Issue: Rejection of “An Act respecting Pharmacare” Bill C 64 TO: SOCI - Standing Committee Social Affairs, Science and Technology From: Onion Lake Cree Nation, Treaty No. 6 (Medicine Chest) Rejection of Bill C-64 “An Act respecting Pharmacare”: 1. As Okimaw of the Onion Lake Cree Nation I am providing OLCN’s written rejection to Bill C-64 “An Act respecting Pharmacare.” 2. Onion Lake Cree Nation is part of Treaty No. 6 which includes the Medicine Chest. 3.

It is the opinion of Onion Lake Cree Nation that Treaty First Nations should not be included under this legislation, as it will create a legal structure contrary to the spirit and intent of the Medicine Chest clause, opening a patchwork of private and public plans instead of upholding the honour of the Crown as it relates to Treaty obligations as they relate to the Medicine Chest Treaty No. 6. Onion Lake Cree Nation fully rejects Bill C-64 “An Act respecting Pharmacare.” 4.

The state of Canada already has an obligation to the Medicine Chest through Treaty No. 6 and should instead uphold the honour of the Crown by better fulfilling the spirit and intent of the Medicine Chest and its obligations to medication coverage, products needed, and comprehensive healthcare to Treaty First Nations. Lack of Consultation: 5. First Nations were not consulted on the guidelines for the formulary for the medications that will be covered or the products required to support individuals with diabetes or contraceptives. 6.

OLCN has been clear on this point numerous times in the past, but we wish to reiterate it again; neither the Assembly of First Nations nor any other entity speaks for, or represents, OLCN and its citizens in relation to its treaty relationship with the Crown, and the rights that flow from such a relationship. The Crown’s treaty relationship is with

2 OLCN, not a political corporate body that is not privy to the treaty relationship. 7. Firsthand lived experience leaves our Nation with concerns that decisions would be under the discretion of the Federal and Provincial governments and our free prior and informed consent will not be upheld. Concern over the state of Canada’s Legislative Agenda: 8. We remember the First White Paper. We see a similar intent in both Bill C-64 and its implementation, Bill C-15 and its Strategic Plan and the legislative Agenda generally. 9.

OLCN concern over Bill C64 is that it is just the latest example of Government enacting Legislation about, but not necessarily with or in the best interests of, Treaty People. This is especially so given the Medicine Chest clause is an obligation that if not upheld will impact the honour of the Crown. The Medicine Chest is a critical obligation which impacts all Treaty people, and its spirit and intent must be upheld fully. 10. We have reviewed where pharmacare will be placed legislatively, and in its placement under Health Canada this leaves Treaty First Nations disjointed.

First Nations have been removed under Health Canada and placed under ISC for Health with First Nations Inuit Health Branch – this legislative alignment additionally puts First Nations in a high impact outcome with legislations such as Bill C-64. 11. OLCN is aware of the plan by the state of Canada to strike down the Indian Act as per the C-15 Strategic Plan. OLCN sees this as a concern if Canada uses C-15 in connection with Bill C-64. If C- 64 passes and the Indian Act is struck down OLCN can see that it will then result in ending the Non-Insured Health Benefits program for First Nations Treaty people.

It is clear then that Canada would not be upholding the honour of the Crown and its side as a Treaty partner

3 who must fulfill an obligation to the Medicine Chest if this action were to occur. 12. OLCN believes that Bill C-64, along with other legislations, are continuing a path of the municipalization of indigenous peoples under the guise of progressive change in the spirit of reconciliation. To be clear, OLCN, as indigenous peoples, have an international identity that must not only be respected to allow real progressive change to take place, but also for the Crown to live up to its legally binding obligations as a treaty partner and its commitments made within the international context.

The continued attempts to place OLCN into a subservient municipal position under the guise of “self-governance”, failing to recognize and respect our inherent and treaty rights and identity as subjects of international law, is both repugnant and damaging to our relationship with the Crown. 13. OLCN does not agree with a Pan Canadian agenda that will influence future policies and decisions, as this just leads further down the road of municipalization of First Nations. We will not give up our inherent sovereignty that the Creator has given us since time began. 14.

It is clear that the provinces will have a significant role in the Pharmacare Implementation, and it is unclear what the bi-lateral agreements will contain. Treaty was not made with the provinces and the off-loading to the provinces is not acceptable to OLCN. Critical Issues with C-64 and impacts to OLCN members: 15. Specific Concerns regarding Bill C-64 itself are the lack of Consultation; Effect of the Health-to-ISC transition; loss or diminution of Uninsured Health Benefits 16.

The Bill states that it is declared as “Single Payor/First Dollar,” and is not a mixed payor model, and this will result in detrimental outcomes to access medications, and this legislation will result in harm.

4 17. OLCN has already seen that private coverage became mandatory through the mandatory coordination of benefits under NIHB which off loaded coverage for First Nations to privatized insurance plans for medications and supports. 18. Since First Nations Inuit Health Branch changed its policy to make Non-Insured Health Benefits “payor of last resort,” First Nations still have negative impacts from its implementation. Federal reportsi note there remain challenges related to awareness of the policy which still creates barriers to medications and coverage today.

The federal government evaluationii noted that “the lack of clarity on the role of the Program as a ‘payer of last resort', creates impacts on service delivery.” The federal government sent out letters to all providers and insurers regarding their policy and First Nations were left with the aftermath of struggling to access medications and services by advocating for themselves in a system that was not laid out to coordinate coverages.

First Nations patients were asked to re- use products that were meant for one-time sterile use, medications were held up in appeals processes, and many providers rejected providing coverage instead of working to coordinate plans. 19. It is also clear that if pharmacare establishes the minimum standard for accessing coverage the erosion and eradication of NIHB for First Nations will happen in time very quickly. 20. It is also understood that there is risk that it will create a market- based incentive to de-list coverage through private insurers for anything covered under C-64.

Historically, NIHB policies have followed suit with such impacts, and we would expect then that this will also happen to NIHB coverage for First Nations simultaneously as FNIHB looks for opportunities to reduce and erode/eradicate coverage under NIHB and/or off load the obligation as it relates to the Medicine Chest. Off-loading the coverage of medications and products for First Nations further to private insurance companies and in addition to the plan under C-64 if passed which is fraught with issues and barriers.

5 21. It is very likely that the coverage we get under NIHB will be at the very least detrimentally eroded or eradicated (delisting of coverage will occur over time) if C-64 is passed. It is understood that this would be similar to or have the same impact that non-First Nations are concerned about with their private coverage from market drift. It would seem that this may be a strategic outcome planned for by Canada through Bill C-64. 22.

Other specific Concerns are regarding the impact Pharmacare will have on OLCN presently for OLCN members that desperately need consistent medications and supports in the areas of diabetes and contraceptives (current rates of Sexually Transmitted Diseases and prevention). 23. Dispensing Fees for Pharmacists are not included and will also mean that First Nations would be left with a gap as First Nations would not be covered for this cost. First Nations are not covered under provincial plans. It would create another Jordan’s Principle type gap and implication. 24.

The Bill does not have to comply to “Clinical Practice Guidelines” either which are provided by Diabetes Canada, and further to this OLCN is aware that Bill C-64 has outdated drug formularies and lists of outdated products. 25. First Nations have always been vulnerable to wait times and access to appropriate levels of care including access to medications and supports. In a time when pharmacists have been given scope of practice where they can help reduce wait times, it is vital to ensure that we do not support legislation that would eliminate this for the most vulnerable.

Onion Lake Cree Nation members affected by Diabetes and STI’s: 26. As Okimaw for OLCN I remain extremely concerned about anything affecting the obligations with regards to the spirit and intent of the Medicine Chest under Treaty No. 6. It is with deep concern that I share that our Nation currently has cases of individuals that live

6 with Diabetes that have sharply increased from 455 cases in 2022 to 825 as of 2024. 27. As you are well aware that the chronic conditions that further develop from Diabetes can be life threatening over time if the right treatments are not available or simply are not provided. 28. In addition, the access to appropriate contraceptives should also not be affected and should remain accessible to those that need them. 29. The rate of sexually transmitted diseases has been an on-going concern over the last number of years for First Nations.

OLCN saw an alarming increase in sexually transmitted diseases as a spike and increase happened pre-pandemic, during the pandemic and then a decline in rates has been trending as of 2023-2024.iii 30. I take the health of our Onion Lake Cree Nation members seriously and I cannot ignore that disruptions or barriers to contraceptives or medications will have grave implications.

If barriers are implemented by requiring OLCN members to be included under Bill C-64 then the risk will be that further skyrocketing rates of those affected by Diabetes will increase and those that need contraceptives may also be impacted and the rates for STIs will also increase instead of decrease as we have seen over the past few years (see Appendix A). 31. I also am aware that pharmaceuticals represent 45% of medical costs for individuals, which are the worst burden for those that are vulnerable. 32. Onion Lake Cree Nation firmly fully rejects Bill C-64 “An Act respecting Pharmacare”

7 “Appendix A” Onion Lake Cree Nation – Communicable Disease Control and population data, Date updated: September 27, 2024, Report Prepared By: FNIHB-ISC Saskatchewaniv Reportable Communicable Diseases in Onion Lake, 2019 – 2023

Summary: • The case rate of Chlamydia has been fluctuating at a high level in Onion Lake since 2019, with the most recent 2023 rate at 2889.8 per 100,000 population. • Gonorrhea case rates increased significantly over pandemic years in 2020 (1554.8 per 100,000 population) and 2021 (1516.9 per 100,000 population) which declined drastically after that. In 2023, gonorrhea case rate for Onion Lake was 694.4 per 100,000 population. • A declining trend was observed for hepatitis C between 2019 and 2023.

No hepatitis C case was reported from Onion Lake in 2023. • An increasing trend was observed for infectious syphilis which peaked at 1633.6 per 100,000 population in 2021. A declining trend is observed since then and in 2023 the case rates for infectious syphilis for Onion Lake was 582.4 per 100,000 Figure 5. Sexually Transmitted Blood-Borne Infections (STBBI) case rates for Onion Lake Cree Nation, 2019-2023.

8 i https://www.canada.ca/en/health-canada/corporate/about-health-canada/accountability-performance- financial-reporting/evaluation-reports/summary-2009-2010-2014-2015-first-nations-inuit-suplementary- health-benefits-program.html ii https://www.canada.ca/en/health-canada/corporate/about-health-canada/accountability-performance- financial-reporting/evaluation-reports/summary-2009-2010-2014-2015-first-nations-inuit-suplementary- health-benefits-program.html iii Onion Lake Cree Nation – Communicable Disease Control and population data, Date updated: September 27, 2024, Report Prepared By: FNIHB-ISC Saskatchewan, “OLCN case rate of Chlamydia fluctuated at a high level since 2019, with the most recent 2023 rate at 2,889.8 per 100,000 population.; OLCN Gonorrhea case rates increased significantly over pandemic years in 2020 (1,554.8 per 100,000 population) and by 2021 declined slightly (1,516.9 per 100,000 population).

In 2023 there was a drastic decline, of the gonorrhea case rate which was 694.4 per 100,000 population.; An increasing trend was observed for infectious syphilis which peaked at 1,633.6 per 100,000 population in 2021.

A declining trend was observed since then and in 2023 the case rates for infectious syphilis was 582.4 per 100,000.” iv Onion Lake Cree Nation – Communicable Disease Control and population data, Date updated: September 27, 2024, Report Prepared By: FNIHB-ISC Saskatchewan 2019 2020 2021 2022 2023 Chlamydia 2836.9 2025.9 2170.4 1777.6 2889.8 Gonorrhea 1040.2 1554.8 1516.9 569.7 694.4 Hepatitis C 165.5 117.8 93.3 68.4 0.0 HIV 0.0 0.0 23.3 0.0 44.8 Infectious Syphilis 496.5 1107.2 1633.6 706.5 582.4 0.0 600.0 1200.0 1800.0 2400.0 3000.0