500-4211 Yonge St., Toronto, ON M2P 2A9 . Tel. 416-599-1925 . Toll-free 1-800-268-7199 . Fax 416-599-1926 . RNAO.ca RNAO submission re Bill C-64 to the Standing Senate Committee on Social Affairs, Science and Technology September 26, 2024

1 The Registered Nurses’ AssociaƟon of Ontario (RNAO) is the professional associaƟon represenƟng registered nurses (RN), nurse pracƟƟoners (NP) and nursing students in all roles and sectors across Ontario. Since 1925, RNAO has advocated for healthy public policy, promoted excellence in nursing pracƟce, increased nurses’ contribuƟons to shaping the health system, and influenced decisions that affect nurses and the public we serve. RNAO welcomes the opportunity to express our support for Bill C-64,

An Act RespecƟng Pharmacare, to the Senate Standing CommiƩee on Social Affairs Science and Technology and thanks commiƩee members for their aƩenƟon to our views on the maƩer. RNAO asks the commiƩee to send Bill C-64 back to the Senate floor unamended and with your full endorsement. Furthermore, we ask that you urge the Senate to pass the bill and move it forward with haste for royal assent.

IntroducƟon RNAO has long advocated for pharmacare, recognized for decades as a missing piece in Canadian medicare.1 Sixty years ago, the Royal Commission on Health Services, also known as the “Hall Commission”, recognized the high cost of life-saving, life-sustaining and disease-prevenƟng drugs and called for prescripƟon drugs to be part of Canadian medicare.2 Yet, according to the Advisory Council on the ImplementaƟon of NaƟonal Pharmacare (the Advisory Council), every major study of the Canadian health system from 1964 through to their report in 2019 commented on the conƟnued lack of pharmacare3, with gaps conƟnuing today.

As nurses, we see daily the detrimental effects of these gaps on the health of those we care for. As the Advisory Council noted: “PrescripƟon drugs are a vital part of health care, helping paƟents to manage and cure disease. But unlike other foundaƟonal pillars of medicare – doctors and hospitals – prescripƟon drugs used outside of hospitals are not part of basic health insurance.

In this respect, Canada is unique among all other industrialized countries with universal systems of public health care coverage.”4 The recent advent of Bill C-64 – although limited to coverage of specific prescripƟon drugs and related products intended for contracepƟon or the treatment of diabetes – does show meaningful progress in addressing this shorƞall. And, the bill creates some of the insƟtuƟons needed for a meaningful expansion of pharmacare across Canada.

For example, it sets out powers and obligaƟons of the Minister of Health with respect to the development of a naƟonal formulary and a naƟonal bulk purchasing strategy thereby laying the groundwork for the number of reimbursed drugs to be expanded and for costs to go down. Altogether, Bill C-64 represents a very real and meaningful step toward a full pharmacare program and an expansion of medicare that will see Canada – at long last – catch up with our counterparts in other industrialized countries.

So, it’s Ɵme to affirm Canada’s commitment to pharmacare and to conƟnue to build upon the foundaƟon of a universal system of publicly-funded health care laid so long ago in our country. We urge you to send Bill C-64 back to the Senate floor unamended and with your full endorsement.

2 Bill C-64 and the progressive realizaƟon of the right to health care RNAO believes that health is a resource for everyday living and that health care is a universal human right. We respect human dignity and are commiƩed to diversity, inclusivity, equity, social jusƟce, and democracy. In these beliefs, we follow the World Health OrganizaƟon 5 and mulƟple internaƟonal convenƟons, including the Universal DeclaraƟon of Human Rights 6 and the InternaƟonal Covenant on Economic, Social, and Cultural Rights 7.

Bill C-64 is a significant step forward in the progressive realizaƟon of the right to the opportunity, equal with other individuals, to make for oneself the life that they are able and wish to have. That opportunity depends on the provision of health care, including, as JusƟce Hall put it in 1964, life-saving, life-sustaining and disease-prevenƟng drugs. Bill C-64 begins a process of increasing access to prescripƟon drugs in Canada.

Current structure of drug coverage and access to prescripƟon drugs As outlined by Carleton University’s Marc–André Gagnon in his submission to this commiƩee,8 the current structure of drug coverage in Canada is highly fragmented. Canada’s 100 public drug plans and 100,000-plus private plans form a confusing patchwork of coverage with yawning gaps through which many Canadians fall. Thirty-nine percent of prescripƟon drug expenditures in Canada are covered through public provincial and territorial plans. All such plans cover seniors and social assistance recipients, though in different ways and to a different extent.

The federal government also has a drug plan that includes First NaƟons people and Inuit as well as the military, the RCMP and refugees. Federal expenditures account for just three per cent of total drug expenditures in Canada. In total, Canada’s public expenditures on prescripƟon drugs are the fourth-lowest amongst member countries in the OrganizaƟon for Economic Co-operaƟon and Development (OECD) – just ahead of Poland, Bulgaria and Chile – leaving lots of room for private insurers to fill the gap.

Private drug plans, mainly provided by employers, account for an addiƟonal 37 per cent of total drug expenditures in Canada. Of course, drug expenditures covered by private insurance plans most oŌen have to be supplemented to some extent by co-payments and deducƟbles. These types of payments form part of the 20 per cent of total drug expenditures that come out of the pockets of Canadians. Out of pocket expenditures also include prescripƟon drug expenditures that are not covered by public or private insurance formularies and the prescripƟon drug expenditures of Canadians who have no coverage at all.

One in five Canadians (21 per cent) fall into the laƩer category, reporƟng zero prescripƟon drug coverage. As Gagnon notes, “Consequently, access to medicines is sƟll conceived of in terms of privileges offered by employers to employees.”9 Current cost of drugs and access to prescripƟon drugs Access to prescripƟon drugs in Canada is further limited by their very high cost in this country.

As Gagnon states, “Canada is characterized by both high costs per capita for prescripƟon drugs and a significant proporƟon of the populaƟon who cannot access the drugs they need.”10 Canada ranks third among the 38 member countries belonging to the OECD in per capita expenditures on pharmaceuƟcal goods. That high per capita cost burden is due to the fact that the price of patented drugs in Canada is second highest in the world, with prices 28 per cent more expensive than the OECD median. Moreover, the price of generics is 45 per cent more expensive than the OECD median.

3 Many Canadians do not fill the prescripƟons they need, or skip or lower doses, due to the high costs of medicaƟon:  A 2024 naƟonal poll reported that nearly one in four Canadians – 22 per cent – split pills, skipped doses, or did not fill or renew a prescripƟon due to cost.11  A 2022 study canvassing pharmaceuƟcal access and use during the pandemic reported that more than 10 per cent of Canadians were not filling prescripƟon doses or were skipping doses.12 Cost-related non-compliance with prescripƟons creates an enormous health burden and an enormous burden on the health system.

As JusƟce Hall said aŌer releasing his seminal report, “The only thing more expensive than good health care is no health care.”13 The facts 60 years later: 10 per cent of Canadians with chronic condiƟons end up in the emergency room due to worsening health because they were unable to afford prescripƟon medicaƟons14, and more than 600 people die every year in Canada from ischemic heart disease because they cannot afford their medicaƟons.

As noted by the Advisory Council in 2018 – proving JusƟce Hall right – exƟnguishing out-of-pocket expenses for just three health problems (diabetes, cardiovascular disease and chronic respiratory condiƟons) would result in a potenƟal savings of $1.2 billion realized from at least 220,000 fewer visits to emergency rooms and 90,000 fewer hospitalizaƟons.15 The evidence is clear: failing to invest in universal prescripƟon drug coverage results in preventable deaths and makes people’s health worse.

Cost-related non-compliance with prescripƟons contributes to the premature deaths of up to 640 Canadians with ischemic heart disease and up to 420 premature deaths among working-age Canadians with diabetes every year.16 And, tens of thousands of Canadians aged 55 years or older suffer cost-related or non-compliance-related health deterioraƟon each year.17 Access to diabetes medicaƟons and devices Bill C-64 will increase access to necessary medicaƟons and devices for the 3.7 million people in Canada – 9.4 per cent of the populaƟon – living with diagnosed diabetes.

As reported by the Library of Parliament, this number has doubled over the past decade and is expected to conƟnue to rise.18 In addiƟon to the increased number of people diagnosed with diabetes, the number of diabeƟcs using medicaƟon to control diabetes has also been increasing over the years.19 As of 2019, nearly three-quarters of adults diagnosed with diabetes used medicaƟon to control the disease.

In 2015, one in four Canadians with diabetes reported that drug costs affected their adherence to their treatment plan.20 In Ontario, insufficient drug coverage has been a factor in thousands of avoidable deaths of diabeƟcs under the age of 65.

RNAO’s best pracƟce guideline, Assessment and Management of Foot Ulcers for People with Diabetes, outlines the implicaƟons of not minimizing complicaƟons related to diabetes, including enormous societal costs and burdens on the health system and social services.21 A study has shown that mortality rates drop when people with lower incomes living with diabetes qualify of medicaƟon under the Ontario Drug Benefit plan at age 65.22 It has been esƟmated that first-dollar coverage for diabetes products could save over 700 lives annually in Ontario alone.23 Access to contracepƟve medicaƟons and devices According to Health Canada, “cost has been idenƟfied by Canadian contracepƟve care providers as the single most important barrier to access to these medicaƟons.”24 It is esƟmated that there are more than 9 million people in Canada of reproducƟve age – nearly 25 per cent of the total populaƟon.

At present, only a fracƟon of this populaƟon is covered for contracepƟves through a public drug plan.

4 The high cost of contracepƟve drugs in Canada – esƟmated at $300 per year for oral contracepƟves and up to $500 for an intrauterine device – inhibits use, compromises reproducƟve rights and increases the risk of unintended pregnancies.

One U.S. study found that providing free contracepƟves could reduce unplanned pregnancies by 32 per cent.25 Conversely, Health Canada points to studies that have demonstrated that publicly funded no-cost universal contracepƟon can result in public cost savings.26 One example: No-cost contracepƟon could save the BriƟsh Columbia health-care system approximately $27 million per year.27 The cost-saving potenƟal of universal, single-payer pharmacare Many studies point to the net cost savings of universal, publicly-funded, single-payer pharmacare, as recommended in the Advisory Council’s 2019 report.28 The Advisory Council anƟcipated an iniƟal cost of $3.5 billion to launch a naƟonal program with universal coverage for essenƟal medicines only.29 Over Ɵme, that cost to government, with the implementaƟon of a comprehensive formulary, was anƟcipated to grow to $15.3 billion.30 In this case, however, big investments will lead to big rewards – and net savings – for Canadians.

The Advisory Council esƟmated net savings in system-wide spending on pharmaceuƟcal drugs of $5 billion per year.31 The Parliamentary Budget Office arrived at a similar conclusion.32 Even with anƟcipated public sector costs of $13.4 billion by 2027–2028, pharmacare would provide a net benefit of $2.2 billion to Canadians.33 Much of the net savings from pharmacare come from increased bargaining power under a single-payer system.34 One esƟmate shows that confidenƟal rebates secured by public drug plans are equivalent to 20 – 29 per cent of the official price of patented drugs.35 This represents $3.9 billion annual savings on only 42 per cent of total drug expenditures in Canada.

Annual savings would be much greater with a single payer that also purchased for the one in five Canadians who currently have no coverage at all. We note that the power and interests of private drug plans are vastly different.

Rebates, when secured, are only a fracƟon of those obtained by public drug plans; they generally translate into profit for shareholders, not lower costs for the insured.36 Indeed, co-payments and deducƟbles conƟnue to be based on “official” – not rebated – drug prices.37 Equitable access to health and health care Coverage for prescripƟon drugs and related products intended for contracepƟon or the treatment of diabetes will increase equitable access to health and health care and demonstrate more broadly the potenƟal of pharmacare to realizing the right to health and health care.

Health Canada tells us that contracepƟves were included in Bill C-64 “specifically because improved access to contracepƟon improves equality… Some populaƟons are disproporƟonally affected by the lack of coverage. Women, people with low incomes and young people, all of whom are all more likely to work in part-Ɵme or contract posiƟons, oŌen lack access to private coverage. One study found that women and girls from lower-income households are more likely to use less-effecƟve contracepƟve methods or no contracepƟve method.”38

5 Similarly, coverage of drugs and products related to the treatment of diabetes will advance the right to health and health care. Broadly speaking, we know that the cost of prescripƟon drugs land unequally on people in Canada; immigrants and racialized persons are less likely to have insurance to cover costs of medicaƟons.

Specifically:  more immigrants (29 per cent) than non-immigrants (17 per cent) reported a lack of coverage for medicaƟon, and  more racialized persons (29 per cent) than non-racialized, non-Indigenous persons reported a lack of coverage for medicaƟon.39 Similarly, health outcomes or disease incidence tends to land unequally on the populaƟon: a key example is diabetes. Health Canada advises that diabetes disproporƟonately affects certain populaƟons within Canada.

Evidence shows that First NaƟons and MéƟs people, and people of African, East Asian and South Asian ethnic backgrounds have higher rates of Type 2 diabetes compared to the general populaƟon.40 Conclusion Sixty years have passed since the Royal Commission on Health Services outlined the need to include the cost of pharmaceuƟcal drugs under medicare in Volume 1 of its extensive report. Although called the “Hall Commission” (aŌer its chair, JusƟce EmmeƩ Hall), one of the six other eminent commissioners was Dr. Alice Girard, a registered nurse. And, JusƟce Hall and Dr.

Girard worked together again on the 1979 Health Services review 41 which cemented medicare into Canada’s social safety net. As nurses do, Dr. Girard went about her important business quietly and to great effect. One can easily see the nursing perspecƟve in these two seminal reports from the 20th century. The work of nurses across Canada is a daily reminder of the value of universally accessible and publicly-funded health services.

Yet, our 21st century nurses conƟnue to see daily the harms that result when the people they give care to cannot afford or access the medicaƟons and medical supplies they need to get and stay well. As outlined above, the commitment to cover diabetes and contracepƟon medicaƟons and supplies is a promising start – but much more is needed to ensure all Canadians can access the medicaƟons they need when they need them. ConƟnued failure to invest adequately and broadly in pharmacare will cost lives.

The government has an important role to play in making the upfront investments needed that will ensure the longer-term prices and savings sorely needed in a country in which people pay the third- highest amount on prescripƟon drugs per capita. Our nurses know that health inequiƟes will persist as long as health care – including universal, single- payer pharmacare – is not fully and universally available and accessible in this country. Women, young people, seniors and equity-seeking groups who have less access to jobs that would provide them private drug coverage will all pay a steeper price down the road.

Bill C-64 is an opportunity to take a significant step forward in the progressive realizaƟon of the right to health care. We urge you to move the Bill back to the Senate floor, unamended, with haste.

6 References 1 See for example: RNAO. (2019.) Universal Pharmacare. Available at: RNAO.ca/sites/rnao- ca/files/Pharmacare_QPD_2019_Final_Public.pdf; RNAO. (2018.) RNAO Submission to the Advisory Council on the ImplementaƟon of NaƟonal Pharmacare. Available at: RNAO.ca/sites/rnao- ca/files/RNAO_submission_on_a_NaƟonal_Pharmacare_Program_final_2018_1.pdf. 2 Government of Canada. (2018). Towards ImplementaƟon of NaƟonal Pharmacare: Discussion Paper.

P .31 hƩps://www.canada.ca/content/dam/hc-sc/documents/corporate/publicaƟons/council_on_pharmacare_EN.PDF, 3 See above note 2. 4 See above note 2. 5 See for example: WHO. (2017). Access to essenƟal medicines as a part of the right to health. Retrieved from: hƩp://www.who.int/medicines/areas/human_rights/en/; WHO. (2014). Access to essenƟal medicine. Geneva: World Health Assembly. WHA67.22. Retrieved from: hƩp://apps.who.int/medicinedocs/documents/s21453en/s21453en.pdf 6 United NaƟons. (n.d.).

Universal DeclaraƟon of Human Rights. hƩps://www.ohchr.org/sites/default/files/UDHR/Documents/UDHR_TranslaƟons/eng.pdf 7 United NaƟons Human Rights Office of the High Commissioner. (2017). InternaƟonal Covenant on Economic, Social and Cultural Rights. Retrieved from: hƩp://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx 8 Gagnon, M-A. (2024.) Pharmacare and Access to Medicines in Canada; A Policy Brief. Submission to Senate Standing Affairs CommiƩee on Social Affairs, Science and Technology [unpublished as of Sept. 24, 2024]. Sept. 13.

Pages 2–3. (Note: In the porƟons of our submission focused on current access to and cost of prescripƟon drugs, RNAO relies heavily on the findings outlined by Professor Gagnon in his wriƩen submission to this standing commiƩee, with our thanks to him.) 9 See above note 8 at page 2. 10 See above note 8 at page 10. 11 Canadian Heart&Stroke FoundaƟon. (2024.) “NaƟonal poll finds nearly 1 in 4 people in Canada report measures such as skipping doses, spliƫ ng pills, not filling prescripƟons due to cost”. [News release.] Feb. 13.

Retrieved from: hƩps://www.heartandstroke.ca/what-we-do/media-centre/news-releases/one-in-four-canadians-not-filling- prescripƟons-due-to-cost 12 Cortes, K. and L. Smith. 2022. “PharmaceuƟcal access and use during the pandemic.” Insights on Canadian Society. StaƟsƟcs Canada Catalogue no. 75-006-X. 13 NaƟonal News Watch. (2021.) “The Hall Commission and the introducƟon of medicare”. July 20.

Retrieved from: hƩps://naƟonalnewswatch.com/2021/07/20/the-hall-commission-and-the-introducƟon-of-medicare 14 See above note 12. 15 See above note 3 at page 16. 16 Canadian FederaƟon of Nurses Unions. (2018.) Body Count: The human cost of financial barriers to prescripƟon medicaƟons. Retrieved from: hƩps://nursesunions.ca/wp-content/uploads/2018/05/2018.04-Body-Count-Final- web.pdf 17 See above note 16. 18 Library of Parliament.

(2024) LegislaƟve

Summary: Bill C:64:

An Act RespecƟng Pharmacare – Preliminary Version (Unedited). (April 15.) Retrieved from: hƩps://lop.parl.ca/staƟcfiles/PublicWebsite/Home/ResearchPublicaƟons/LegislaƟveSummaries/PDF/44-1/PV_44- 1-C64-E.pdf 19 StaƟsƟcs Canada. (2023.) Diabetes among Canadian adults. Nov. 19. Retrieved from: hƩps://www.statcan.gc.ca/o1/en/plus/5103-diabetes-among-canadian-adults 20 See above note 18. 21 RNAO. (2013.) Assessment and Management of Foot Ulcers for People with Diabetes (2nd ed.). Pages 15-16. Available at: hƩps://rnao.ca/bpg/guidelines/assessment-and-management-foot-ulcers-people-diabetes-second- ediƟon

7 22 RNAO. (2019.) Universal Pharmacare. Available at: RNAO.ca/sites/rnao- ca/files/Pharmacare_QPD_2019_Final_Public.pdf; Booth, GL., Feig, DS., Bishara, P ., BhaƩacharya, O., Lipscomb, LL., Bierman, AS. & Shah, B. (2012). Universal drug coverage and socioeconomic dispariƟes in major diabetes outcomes. Diabetes Care, 35, 2257-2264. 23 See above note 8 at page 19. 24 Health Canada. (2024.) Universal Access to ContracepƟon. Feb. 29. Retrieved from: hƩps://www.canada.ca/en/health-canada/news/2024/02/backgrounder-universal-access-to-contracepƟon.html 25 See above note 8 at page 18.

For a U.S. perspecƟve, see also: Bailey, Martha. 2023. “Increasing Financial Access to ContracepƟon for Low-Income Americans.” The Hamilton Project. Washington: Brookings. hƩps://www.brookings.edu/arƟcles/increasing-financialaccess-to-contracepƟon-for-low-income-americans/ 26 See above note 24. 27 See above note 24. 28 See for example: Royal Commission on Health Services (Hall Commission). (1964). Volume 1 – 1964.

Print only with online reference here: hƩps://www.canada.ca/en/health-canada/services/health-care-system/commissions- inquiries/federal-commissions-health-care/royal-commission-health-services.html; NaƟonal Forum on Health. (1997.) Canada Health AcƟon: Building on the Legacy – Volume I – The Final Report. Retrieved from: hƩps://www.canada.ca/en/health-canada/services/health-care-system/reports-publicaƟons/health-care- renewal/canada-health-acƟon-building-legacy-volume1.html; Commission on the Future of Health Care in Canada (Romanow Commission). (2002.) Building on Values: The Future of Health Care in Canada.

Print only per web reference: hƩps://www.canada.ca/en/health-canada/services/health-care-system/commissions-inquiries/federal- commissions-health-care/commission-future-health-care-canada-romanow-commission.html; Standing CommiƩee on Health. (2018.) Pharmacare Now: PrescripƟon Medicine Coverage For All Canadians.

Retrieved from: hƩps://www.ourcommons.ca/DocumentViewer/en/42-1/HESA/report-14 29 See above note 2. 30 See above note 2 at page 14. 31 See above note 2 at page 92. 32 Office of the Canadian Budget Officer. (2023.) Cost EsƟmate of a Single-payer Universal Drug Plan. (October 12.) Retrieved from: hƩps://www.pbo-dpb.ca/en/publicaƟons/RP-2324-016-S--cost-esƟmate-single-payer-universal- drug-plan--esƟmaƟon-couts-un-regime-assurance-medicaments-universel-payeur-unique 33 See above note 32 34 See above notes 2 and 32. 35 See above note 8 at page 12.

For an internaƟonal perspecƟve, see also: Morgan SG, Vogler S and Wagner AK. (2017.) “Payers’ Experiences with ConfidenƟal PharmaceuƟcal Price Discounts: A Survey of Public and Statutory Health Systems in North America, Europe, and Australasia.” Health Policy 121 (4): 354–62. Retrieved from: hƩps://doi.org/10.1016/j.healthpol.2017.02.002 36 See above note 8 at page 12. 37 See above note 8 at page 12. 38 Health Canada. (2024.) Universal Access to ContracepƟon. Feb. 29. Retrieved from: hƩps://www.canada.ca/en/health-canada/news/2024/02/backgrounder-universal-access-to-contracepƟon.html 39 StaƟsƟcs Canada. (2022).

Study: InequiƟes in pharmaceuƟcal access and use. hƩps://www150.statcan.gc.ca/n1/daily-quoƟdien/221102/dq221102a-eng.htm 40 Health Canada. (2024.) Universal Access to Diabetes MedicaƟon, and Diabetes Device Fund for Devices and Supplies. (February 29.) Retrieved from: hƩps://www.canada.ca/en/health-canada/news/2024/02/universal- access-to-diabetes-medicaƟons-and-diabetes-device-fund-for-devices-and-supplies.html 41 Federal Commissions on Health Care. (n.d.) ARCHIVED: Health Services Review (1979–1980).

Retrieved from: hƩps://www.canada.ca/en/health-canada/services/health-care-system/commissions-inquiries/federal- commissions-health-care/health-services-review-1979-1980.html