[Recorded by Electronic Apparatus]
Tuesday, October 29, 1996
.1607 
[English]
The Chairman: I'd like to call this meeting of the Sub-committee on HIV/AIDS to order. Under Standing Order 108(2), we are commencing a study on poverty and discrimination.
I notice by the agenda that I am supposed to make an opening statement. I think I'll pass on that and apologize to our witnesses for the lateness at which we're starting. Every now and then we get stuck in the House on a vote and have to do what we're told by our whip and be there.
Without any further ado I will take this opportunity to introduce Pierre Fortier, director of income security policy, strategic policy; and Dr. Laura Heung, medical adviser, CPP income security program.
We would ask you to start. Who is starting?
Mr. Pierre Fortier (Director, Income Security Policy, Strategic Policy, Department of Human Resources Development): Thank you, Mr. Chairman.
I will briefly outline the income measures that are administered by the Department of Human Resources Development, and then we'll be available to you for discussions or questions.
Human Resources Development Canada works with Canadians of all ages to help them achieve their goals throughout life through delivery of education, training, income support and social programs that benefit families and children, youth, workers and employers, seniors and persons with disabilities. The two most important programs administered by the federal government in which HRDC plays a role in providing income support to the disabled are the Canada Pension Plan and the Canada health and social transfer, which provides partial funding for provincial social assistance programs. HRDC also administers the employment insurance program, which provides sickness benefits.
Finally, HRDC operates special programs for persons with disabilities, women and visible minorities aimed at overcoming barriers to full participation in Canadian society, which may be faced by members of these groups.
In terms of the most important income support program HRDC administers, the Canada Pension Plan, the plan is a compulsory, contributory, earnings-related social insurance program that provides income protection to Canadian workers and their families in the event of disablement, retirement and death.
The Canada Pension Plan operates in all provinces except Quebec, which operates its own parallel Quebec Pension Plan. Disability benefits are provided in the event of a severe and prolonged disability to persons who have made contributions to the Canada Pension Plan in two of the last three years or five of the last ten years. The maximum CPP disability benefit in 1996 is $10,451.
There are currently about 1,200 persons with AIDS as their primary diagnosis who are in receipt of CPP disability benefits. There may be additional people who have a secondary diagnosis, like depression, who may be on disability because of this other illness. We have identified 1,200 people who have primarily come on disability because of AIDS. This represents four-tenths of one percent of the current CPP disability caseload of some 300,000 beneficiaries.
.1610
I have given you an annex with a graph that shows the progression of the number of people with AIDS over time who are receiving CPP disability. You can see that the actual number of people started in 1986 and has climbed to about 1,200 right now.
Persons with AIDS who are unable to work and have no other sources of income are eligible for provincial social assistance, which is financed in part by the Government of Canada through the Canada health and social transfer.
In terms of going back to work, although the CPP disability program is really here for people who have very severe disabilities and which may be very prolonged, if they need measures to go back to work, the Canada Pension Plan enacted new guidelines in 1985 to remove barriers to re-employment faced by many disability beneficiaries. We have set out these measures in annex 2.
But the measures that apply more to people with AIDS are those where the CPP now provides clients with three months of benefits after they return to work to help them through the transition to work. Previously, the minute a person returned to work, the person could lose his disability benefit. As you can see, a $10,000 maximum benefit can make a big difference to someone's income. It was seen as a disincentive for people to go back to work.
In addition, disability beneficiaries with recurrent or degenerative disabilities, such as AIDS, will have benefits reinstated on a fast-track basis if the disability recurs and they are no longer able to continue working.
These are, Mr. Chairman, in a nutshell, the major provisions being administered by the department that provide income support for the disabled, particularly those with AIDS.
The Chairman: Thank you very much. Do you have another presentation, or is just one of you making a presentation?
Mr. Fortier: Yes.
The Chairman: Great. We'll go to questions.
[Translation]
Mr. Ménard (Hochelaga - Maisonneuve): In the context of the Committee's review to establish whether there is a real or potential link between discrimination and people's serostatus, the issue of income support is, of course, one of our main concerns.
I would like to ask you a couple of questions. First, could you describe clearly what the process is. Starting when someone discovers that he or she is HIV-positive or when the seroconversion happens, what is the process? Is a recognized medical formula applied? What does the notion of disability cover?
Would you say that people with HIV/AIDS can be considered as suffering from a disabling disease and, as such, can receive benefits? Could you describe the process so that we know what the administrative procedures are and be in a position to make recommendations in case this process seems to be too much of a burden or too exclusionary for the people we are concerned with?
Mr. Fortier: The process a person has to follow is to submit a claim for disability benefits under the Canada Pension Plan. You have to fill an application. I don't have one here, but if you're interested, we could send you one.
.1615
Once the application is filled, the claim is reviewed by the administration. It's possible that, to get additional information, the administration asks that the person concerned see a doctor whose evaluation will complete the information given on the application.
Once you have submitted the required information, a decision is then taken regarding your eligibility. If you're not satisfied with the decision, you can appeal it. If you meet all the requirements, you will get disability benefits.
Mr. Ménard: Let's start at the beginning. Let's say that someone has been working for five years and has paid the required premiums. Suddenly, this person is told that he or she is HIV- positive. At that moment, according to your administration, is there a definition of ``disability'' which applies? Do you have a standard definition?
I know this is something which is difficult to define. I am familiar with the definition given by the Quebec Pension Board. You practically have to be paraplegic, because if you are blind, they consider that you can answer a phone, since you can still hear, and if your deaf, you are still able to stick stamps on envelopes. I hope that your definition is not as restrictive as the one used by the Quebec Pension Board.
Mr. Fortier: It's very similar. I can give it to you in English:
[English]
- (a) a person shall be considered to be disabled only if he is determined in prescribed manner to
be suffering from a severe and prolonged mental or physical disability, and for the purposes of
this paragraph,
[Translation]
This is one aspect. The second one is as follows:
[English]
(ii) a disability is prolonged only if it is determined in prescribed manner that the disability is likely to be long continued and of indefinite duration or is likely to result in death;
[Translation]
As you can see, according to the Canada Pension Plan's definition of disability, basically, what has to be determined is that an individual suffers from a medical condition which substantially affects his or her ability to work.
Mr. Ménard: Then, according to your definition, if members of this Committee are convinced in the end that we shall win the fight against AIDS and that, therefore, AIDS cannot be considered any longer as a disease likely to result in death, but rather as a chronic disease, in the sense that we are going to be able to increase the life expectancy of people with AIDS, then, if we took this new approach, we could exclude people with AIDS from the category of those who are considered ``disabled''.
Mr. Fortier: This is an approach which is not new to us, it applies not only to AIDS but also to several other diseases. Medical science does progress and some people who were considered disabled under the Canada Pension Plan can, to a certain degree, regain some ability to work. This is one of the reasons why we changed our eligibility criteria.
For instance, in the case of someone who was, at one point, eligible and who can return to work because his or her health is better, the evaluation will be fast-tracked and the same disability determination process will not apply.
Mr. Ménard: We're going to hear shortly the Canadian AIDS Society. They claim that there are around 50,000 people living with HIV in Canada and that this number is going to double within the next five years. So, there are 50,000 HIV-positive people and probably around 15,000 people living with AIDS.
.1620
You indicated that 1,200 people are included in your statistics. Let's say there are 10,000 people living with AIDS in Canada, if you exclude Quebec which has its own Pension Plan. How do you explain that only 1,200 people are eligible to receive disability benefits?
Mr. Fortier: AIDS is a progressive disease and its impact on an individual's ability to work can be felt at a later stage of the disease's development.
When someone is declared HIV-positive, it does not mean that this person immediately becomes unable to work. It might take a few years until that person loses his or her capacity to work.
Given the fact that the Canada Pension Plan does not make any allowance for people who have almost lost their capacity to work, a few fall into that category.
Mr. Ménard: Nevertheless, I suppose you have to make a difference between HIV-positive people and people living with AIDS.
Mr. Fortier: Of course.
Mr. Ménard: Later on, the Canadian AIDS Society is going to give us their statistics, but I saw somewhere that there are 50,000 HIV-positive people in Canada, which means 50,000 people living with a virus which is not necessarily active right now.
You told us that to make a claim under your program, the first step for the potential beneficiary was to fill out an application, but that there is no real medical evaluation at that time.
Mr. Fortier: There is a medical evaluation at the same time.
Mr. Ménard: As far as reviewing the case is concerned, if the application is denied at this stage, there is an appeal process.
Mr. Fortier: Yes.
Mr. Ménard: Which is under the jurisdiction of the Department of Human Resources Canada?
Mr. Fortier: There are three stages.
The first one is a review by the Minister. At this stage, the case is reviewed by the administration. If the ruling is still not favourable, the claimant can appeal to a Review Board including one legal expert, one health expert and a third person. These people are trained to interpret the Canada Pension Plan Act and have a lot of experience in evaluating such cases.
They make a ruling and if it's still not favourable, the claimant can appeal to the Pension Appeals Board, that is at the third level of the evaluation process.
Mr. Ménard: I'll come back to that when you have a second round of questions, Mr. Chairman.
[English]
The Chairman: Mr. Ringma.
Mr. Ringma (Nanaimo - Cowichan): I have a very basic question. As you are aware, this subcommittee is on HIV/AIDS, and your presentation here just concentrates on AIDS; you don't mention HIV. Is that because there is no dependence on CPP by HIV sufferers, or is it because you lump it all together, or what?
Dr. Laura Heung (Medical Advisor, Income Security Program, Department of Human Resources Development): Can you clarify your question, please?
Mr. Ringma: This subcommittee is looking at the effects of poverty, discrimination, etc., on HIV and AIDS. I know there is a progression from HIV to AIDS, but in your presentation you're talking only of AIDS. Therefore, is HIV ignored, or is it simply not a factor?
Mr. Fortier: No, it's a matter of progression in the evolution of the condition. In most instances we will provide a disability pension to the person who has developed AIDS and it has affected the individual's capacity to work.
.1625
Mr. Ringma: Let me try it another way. This may simply stem from my own ignorance of the malady. Can you put people in the categories of those who have HIV and those who have AIDS - and you're assuming they're going to progress from one to the other? Can you put them in two categories, and if so, are there no HIV sufferers who are saying, I need assistance, I do not yet have AIDS, but I'm incapacitated and I need help?
Dr. Heung: In general, if they are just HIV-positive, people are asymptomatic. That means it doesn't affect their ability to work, and benefits are granted only to people who are affected and have lost their functional capacity to work.
Mr. Ringma: I think I have the answer fairly clear that those just suffering from HIV are not yet incapacitated.
It begs the other question this committee is asking, of course, which is what medical treatment, drugs etc...? That's not your domain, and I understand that, but it's a question we are asking ourselves. What drugs should they get, and do they get, if they are just HIV sufferers and have not progressed to the full AIDS?
Mr. Fortier: To elaborate a little on your question, some people with HIV symptoms could get CPP disability, but it might be because of a secondary condition. When they learned they had HIV, the people could have become very depressed and they would no longer be able to work because of the depression.
Mr. Ringma: Yes, I understand.
Mr. Fortier: In this case, our statistics might show them as depressed as opposed to HIV-positive. That's for the main condition.
Mr. Ringma: That's a worthwhile elaboration for me. That's kind of the direction -
The Fortier: The main condition will be the most severe condition at the time of determination.
Mr. Ringma: My second question has to do with the fact that this committee again is looking at the effects of deprivation, discrimination, or suchlike. Your presentation says these are the rules of CPP, this is what we allow, and I think you say you have 1,200 people who -
Mr. Fortier: Yes.
Mr. Ringma: Besides that, you must have a number of people who are saying, look, I need help, but they do not yet fall into that category of being disabled. You have your rules to determine what is and what isn't -
Mr. Fortier: Right.
Mr. Ringma: You must have all these people - the whole lot - visible, so in your experience, are there negative effects you can see from your departmental policies having to state, sorry, you don't fall under the rules and therefore we cannot supply you with CPP relief?
The aim of this committee is to determine what effect the lack of funding, lack of support and everything else have on people who are in this category of suffering.
Mr. Fortier: CPP is part of a broader network of programs for people. By all means, CPP is not the be-all and end-all. It does leave out a lot of people who may have partial disabilities, or may not have sufficient disability to qualify.
Other programs may provide coverage for these people, and they may have an employer pension plan that might provide sickness and disability benefits, but not all the population is covered by such programs. Other types of programs that might provide benefits - but it is not likely in this case - are workers' compensation programs. They would have to have an accident on the job site if they got a benefit from that program, so they would not necessarily be related to HIV.
The only other programs that would provide assistance would be provincial assistance programs if the person did not have sufficient income and lost their capacity to work, but were not sufficiently disabled to qualify for a CPP disability.
.1630
Mr. Ringma: I appreciate that my question really should be properly placed to someone in the category of an AIDS sufferer, or the representative of an AIDS sufferer, saying, look, these are the barriers we're up against: we hit CPP, we're denied; we hit here, we're denied; we hit.... They would probably give me a better answer.
So it's a little unfair, and I appreciate that, asking you to put yourself in the position of those denied.
I would like to ask a final question, which I think you can readily answer. As you look at your budgets next year and the following year and you see the growth in AIDS sufferers, what's the effect on what you're putting into your future budgets? By what amount are you increasing it?
Mr. Fortier: I don't have the numbers here, but I could obtain the information from our chief actuary with the Office of the Superintendent of Financial Institutions, who does these projections for us. Whenever he does a projection for the Canada Pension Plan, he will take into account the growth in caseload for the AIDS category.
Mr. Ringma: I'd like to get that, because apparently it's very predictable. I'd like to see that you have the planning there on the books. We'll get that for the committee.
The Chairman: We can request that through the committee and have it circulated.
Madam Ur.
Mrs. Ur (Lambton - Middlesex): Thank you, Mr. Chairman.
I thank you for your presentation. I'm certainly familiar with Canada Pension disability applications, having been a constituency assistant for seven years. I can pretty well fill them out with my eyes shut.
I, too, have the same concerns as my honourable colleague with the increase in numbers from 1985 to 1995. I'm looking forward to those figures, because it certainly will play havoc with the budget, with the CPP, even with the disabilities -
I know that when I worked in the office, even when there was a change in employment, when factories were closing down, in my area especially, individuals would come to the office. If one person applied, well, then you had about 50 applying, thinking they'd fall under the same umbrella. Finally, after about the 40th application, you said, would you really be filling this out if you had a job? No, but we're trying to get on to some kind of assistance.
It's much as you had said. There are the provincial social services that try to get them off their system: go to the feds and apply for disability; I'm sure you're going to get it. It's just one government against the other.
You made a few interesting statements...that there is funding available for secondary conditions, say, depression. Is this just HIV/AIDS, or does that apply to anyone else applying for a disability pension?
Mr. Fortier: Yes.
Mrs. Ur: I find that interesting.
Mr. Fortier: We're not focused on any particular illness. The CPP will look at the health condition of the individual and how that affects the individual's capacity to earn at a substantially gainful occupation.
It may be one condition; it may be a combination of various conditions. It may be physical. It may be mental. It may be both at the same time. But having determined the health situation of the individual, we look at the impact of this condition on the person's earning capacity.
Mrs. Ur: Do you have any stats on that, as to one disability application compared to another, as to the degree in a secondary kind of application?
I'm also aware of the fact that the disability criteria for CPP are totally different from Revenue Canada's disability criteria. We always had people coming in saying, well, I'm qualified under one, but not the other kind of thing, and they're all falling under the federal government.
I do think the three-month guideline is a good incentive for people to try to get back to work, to see if they can actually be in the workforce again.
You said you can streamline the process for HIV/AIDS applicants who say they've tried to go back to work and can't. Is that same process used for everyone who tries to go back and is unable to for whatever reason?
.1635
Mr. Fortier: If they have a recurring condition like AIDS or -
Mrs. Ur: What's the timeframe? You say streamline. What are you looking at? How fast can you get that kind of application done?
Dr. Heung: As soon as we receive the application or a letter saying they are unable to continue the work, the benefit will be continued, and so it will go to the processing unit.
Mrs. Ur: What is the timeframe now for an application to be reviewed, accepted or denied? How long?
Dr. Heung: Right now it is regionalized, so it depends on the region.
Mrs. Ur: I know it hasn't improved in southwestern Ontario.
Dr. Heung: I'm unable to answer your question.
Mr. Fortier: We could review the timeframes for that. We do have a statistical table that shows the number of beneficiaries by various categories of diagnosis. We will table that with you. I don't have it here.
Mrs. Ur: I think it's really important to get out the information the chair has requested. As the government has been reviewing CPP, I think it's really important to get out these kinds of stats to know what our challenges are down the year.
Having the retirement and the disability...the one seems to be weighing more heavily on the program than the other, and the dollars being put in for the retirement part seem to be in the process of being gobbled up by the disability aspect.
Mr. Fortier: There is a quinquennial review going on right now by the federal government and the provinces. It's looking at the financing of the Canada Pension Plan.
Prior to the review the chief actuary had put out his 15th actuarial report, which indicated that if no changes are made, by 2030 the pay-as-you-go rate would reach about 14.2%. That is about1% higher than the figure in the previous report. The main reason for the increase was the projected increase in disability costs.
On the growth of AIDS, as you can see, 0.4% is not very large in the total picture, and it was not one of the primary causes of the growth in the cost of disability. They were more related to the trauma situation, to changes in legislation that broadened the access to disability to late applicants, and also to some changes in the way the administration was determining eligibility at one point, based on appeals rulings.
We had started using socio-economic factors in determining the capacity of an individual to work. Subsequently we got some further appeal ruling that brought it back to a tighter basis for determining a disability.
The combination of these various factors militated in favour of causing a very significant increase in pay flows in a fairly short period of time. Based on that trend the chief actuary projected a fairly significant increase in disability costs.
That situation is being reviewed, and the federal-provincial discussions.... Not only the contribution rate, but also possible changes to benefits are being considered.
Mrs. Ur: Are the criteria still two out of the three, or five out of the ten years' contribution time?
Mr. Fortier: Yes, that's what it is now, but the consultation document that was put out in the review process contains some measures to tighten up disability.
One of them would be to bring back the criteria to four of the last six rather than two of the last three. Basically this would tighten the contributor requirements, the administration, and a range of other measures that would have reduced the amount of the retirement benefit paid to disabled persons when they reached retirement age.
.1640
Mrs. Ur: Do denials still operate in such a way that if a person applies for CPP disability and the doctor writes on the medical form that this person is able to work perhaps with a lighter workload, or perhaps one or two hours per day, an appeal is rejected?
I just wonder if Health and Welfare could provide me with information on where we could find employers who would hire someone for one or two hours a day.
Mr. Fortier: If people have earning capacity that exceeds the value of one maximum retirement benefit, which is about $700, it's possible that the person could be considered to have a substantially gainful capacity.
Mrs. Ur: One hour a day?
Mr. Fortier: Well, one hour a day, I don't know.
Mrs. Ur: I've had some come back. I find that a little, myself.
Mr. Fortier: Some people may be able to earn wages one hour a day.
Mrs. Ur: It would be interesting if you could provide me with those stats.
Thank you, Mr. Chairman.
The Chairman: Thank you. We now go to our five-minute rounds, and we go back toMr. Ménard.
[Translation]
Mr. Ménard: I think it would be very important to know the precise definition you use. We have here an organization which can speak with authority on behalf of people with AIDS, and it's the Canadian AIDS Society.
This organization has this to say about your administration and the eligibility criteria for disability benefits:
- Because of rigid interpretations of disability, which rarely accommodate the fluctuating health
status of people living with HIV/AIDS, many individuals are able and willing to work, but are
discouraged from doing so by the requirements of disability benefit programs.
I lived for a number of years with a spouse who suffered from this disease. Some days, he could come biking with me, go shopping or wash the floor. However, the next day, he could be totally unable to get out of bed. Such is the cyclical nature of HIV. It is extremely difficult for people living with HIV/AIDS to qualify for benefits according to the definition applied by your administration.
Don't you think that in the case of people living with HIV/AIDS, the cyclical fluctuation of their health status should be taken into consideration?
Mr. Fortier: I believe you're perfectly right to make this point. This is one of the reasons why the Minister of the day, Mr. Axworthy, introduced this provision to make requirements more flexible, so that people would be able to go back to work, but could have their benefits reinstated.
It's a rather new provision and we are looking forward to your and other interested people's comments on its impact.
Mr. Ménard: You have included a copy of the press release on the subject in the documents you distributed to the Committee. From your experience, even if in the end, only 0.4% of claimants get disability benefits because of their serostatus, do you think that members of this Committee can be confident that, because of the changes made by Mr. Axworthy, the comment made by the Canadian AIDS Society is going to be taken into consideration?
.1645
Are you telling us that, practically speaking, the cyclical fluctuations of the disease are going to be taken into account and, as a result, people living with HIV/AIDS are going to see their claims approved by the officials who make the rulings?
Mr. Fortier: The objective of this measure, which was submitted to you, was precisely to allow us to be more flexible than before so that we could take into consideration the fluctuations of the disease.
How does this work, practically speaking? To answer that, we would need some feedback.
Mr. Ménard: Okay.
You told us that 1,200 people were receiving disability benefits, in fact, 1,162.
Would you be able to give us some information on those who submitted a claim and whose application was denied? Of course, it's useful to know the number of claimants who do get disability benefits, but this number does not really mean anything unless we know how many people were denied disability benefits under the Canada Pension Plan because of their serostatus.
Mr. Fortier: I would gladly give you the information if we have it.
Mr. Ménard: You must have it.
Mr. Fortier: We should, but I'm not sure. I can't guarantee you we have it. If it is available, we'll give it to you.
Mr. Ménard: Great. Thank you very much.
The Chairman: Thank you. Mr. Szabo.
[English]
Mr. Szabo (Mississauga South): Thank you, Mr. Chairman.
Mr. Fortier, I assume it's fair to say that you basically come here to tell us what the present income support programs are and to clarify if there are any questions about the.... I don't think you're here to comment on the aspects of poverty or discrimination, other than to the extent that -
Are you, or is the department, of the view that anything going on at present with regard to the income support programs is discriminatory so that changes are necessary?
Mr. Fortier: In terms of measures, of which I would have personal knowledge, where there is discrimination against a particular group, I'm not aware that there is such a thing. CPP is non-discriminatory, in the sense that it is based on health condition and the ability to work, no matter what the condition is.
If there were any such indication, we would be very concerned and would want to make any necessary corrections.
Mr. Szabo: So from the standpoint of HRD there's nothing you can add to the study, other than that you're not aware of any?
Mr. Fortier: In terms of discrimination, no.
Mr. Szabo: Thank you.
The Chairman: Are there any more questions, or can we go to the next set of witnesses?
Mrs. Ur: I just have one quick question. How many re-entries are allowed - go in, come out, come in, come out?
Mr. Fortier: Any number. Basically if a person is in this up-and-down situation, it's not a matter of how many, it's a matter of whether they are in that condition.
Mrs. Ur: Do you have any stats on the reviews that were done?
Mr. Fortier: If it's every week or every day, I'm not sure we would necessarily respond to every day. But we're talking about people who actually make the effort to go back to work.
Mrs. Ur: I just wondered, was there a cap on it or anything like that?
Mr. Fortier: Not that I'm aware of, no.
Mrs. Ur: Do you have any stats on the reviews you've done regarding people who are now on CPP disability, on people who were taken off CPP disability?
Mr. Fortier: The number of reassessments?
Mrs. Ur: Yes.
Mr. Fortier: And how many?
Mrs. Ur: Yes.
Mr. Fortier: I don't have that number here, but I can get it to you.
Mrs. Ur: Thank you. I'd like to see it.
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The Chairman: Thank you very much, Mr. Fortier and Dr. Heung, for your time here today. I'm sorry we were rushed and had trouble getting members, but it's one of those days in the House when everyone is kind of hectic. I thank you for your time. You'll be hearing from our clerk on some of the information we asked for. Once again, thank you very much.
Mr. Fortier: You're welcome.
The Chairman: We'll start now by introducing Russell Armstrong, the executive director of the Canadian AIDS Society.
Mr. Armstrong, perhaps you could introduce the person with you.
Mr. Russell Armstrong (Executive Director, Canadian AIDS Society): Thank you,Mr. Chairman. Good afternoon, everybody. I'm joined this afternoon by my colleague, Tasha Yovetich. Tasha assisted me in the preparation of my materials, and she is prepared to help me answer any questions the committee may have.
I'd just like to get a bit of direction. I understood we're to wrap up by 5 p.m. Are we still attempting to do this?
The Chairman: We can extend it beyond that, depending on how long the members can stay. But we're subject to the bells and lights blinking, and so forth, that are calling us back to the House. If they are prolonged and we have to go back to the House, then we'll have to wrap up early; otherwise, we'll try to give you some latitude. So don't be rushed; we're here for awhile.
Mr. Armstrong: Okay.
The Chairman: Mr. Armstrong, you know the rules of the committee. You can make your presentation, and then we'll go to ten-minute rounds, with each person asking questions.
We give lots of latitude to the answerer; I only cut off the questioner. So I'd ask you to start.
Mr. Armstrong: I attend a lot of meetings, and I appreciate the value of succinctness, so we'll try to stick to that.
The Canadian AIDS Society has made a presentation to this committee before. This is certainly the third time I've been before the committee. However, the membership has changed somewhat, so I'd like to just say a couple of words about what the Canadian AIDS Society is.
My presentation this afternoon is going to try to give you an overview of what we consider to be the broad themes in the whole discussion about poverty, discrimination and HIV/AIDS. Our point in doing it this way is that a number of the presenters who will appear before you in subsequent hearing days will address very particular aspects of the question, but we wanted to be the ones to try to touch on all the themes and give the issue some shape.
The Canadian AIDS Society is a national coalition of community-based organizations working in local communities to address the impact of HIV/AIDS across Canada. We have roughly 100 members, and our members are located across the country in virtually every region. We have members in the north, as well as Newfoundland and British Columbia.
At the national level the Canadian AIDS Society has a dual mandate: on the one hand, to speak for the interests of these local community organizations, but also to try to be a voice at the national level, both for affected communities - what we call vulnerable or at-risk populations - and for people living with HIV/AIDS.
The best example I can find to conceptualize what this issue - poverty, discrimination, HIV/AIDS and the impact of the mix of these factors - is about comes from a quote by Jonathan Mann. Some of you may know Jonathan Mann, and I'm actually sure you'll hear this quote a few times from witnesses who will make presentations to you at subsequent hearing dates.
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Jonathan Mann works with the Harvard School of Public Health. He's an international expert on something called health and human rights, something that touches quite deeply on this question of poverty, discrimination and HIV/AIDS. He had this to say in 1994:
- We have seen the [AIDS] epidemic follow the path of least resistance within each society. This
pathway is highly specific within each society and yet fundamentally similar around the world.
The major social risk factor for vulnerability to HIV is to belong - before AIDS ever
appeared - to a group which is discriminated against, marginalized, stigmatized by, and
excluded from society. Most often this discrimination involves race, gender, ethnicity, religion,
age or sexual preference.
We're trying to make the case to this committee that in order to deal effectively with the HIV/AIDS epidemic, you need to address these larger, underlying inequities that affect people's health status and their vulnerability to disease. The reason we have to approach the issue in this way is based on our improved understanding of what affects health outcomes. In our brief we describe a particular approach to health that looks at the facts of doing things like providing universal health care.
Expecting everybody just to be self-interested and to pursue health as a lifestyle choice is a very inadequate view of health. We have to now recognize that there are other, larger social and economic forces at play. It's not just about individual lifestyle choices any more. There are larger forces that affect health beyond individual control.
The conclusion you reach in this analysis is that people at the lower end of the socio-economic scale are at greater risk for disease. What puts people in this particular area of the economic scale are forces that include marginalization, discrimination, physical ability, and the other marginalizing, stigmatizing forces that Jonathan Mann mentions in his quote.
In addition to these marginalizing forces, another aspect we'll dwell on is the fact that we live in a society where our economic well-being is structured in such a way that becoming sick as a result of some of these larger forces also makes you poor.
These equations are fully explained in our brief. We want to focus on how these larger general forces affecting health play out in the specific instance of HIV/AIDS.
The basic point we want to make is that poverty and marginalization put a person at risk for HIV. Your economic status affects how you subsequently fare with the disease once you're diagnosed. But also becoming HIV-positive itself reduces you to poverty.
Taking the first part of the point we're trying to make - poverty, marginalization, and risk for HIV/AIDS - I think if we take a look at current epidemiology, we see this being played out in the most recent trends in HIV transmission. I'm not entirely sure what information was presented to you by Health Canada last week, so some of this may be a bit redundant. But we need it to be fresh in our minds to help us make our point this afternoon.
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One of the important things to remember when we're talking about HIV incidence is that there's a difference between HIV incidence and AIDS cases. At the national level, we often hear the number of AIDS cases quoted. It's important to stress the difference off the top, because it can take up to 10 years for someone who's HIV positive to become diagnosed with AIDS. So if you're given an AIDS statistic, it basically tells you where the epidemic was 10 to 15 years ago. It doesn't necessarily tell you what's happening today.
When we see in our AIDS statistics that the largest group represented in those statistics are, for instance, gay men, it's telling us that 10 to 15 years ago they were the group that was becoming most affected by the disease. It doesn't give us a clear indication of who's being infected today.
In terms of HIV incidence today, we see that after a period of exponential growth of the epidemic in the 1980s in this area, we have a rapid decline in annual sero conversions to a point where the epidemic appears to level off. That's down in this area, and that's where we are today.
This is a general summary curve of overall numbers, but if we try to interpret this and see what's going on beneath that, we see some very disturbing trends. We see that while the annual number of new HIV infections may have declined overall from previous years, within that decline there are certain groups of people who are showing rapid increases in HIV infections.
You can see the upswing here, and what I'm showing is a chart of the HIV infection trends amongst injection drug users, for instance. This curve is climbing fairly steeply.
If I turn the page, we see the annual HIV infection trends for people who fall into the general heterosexual risk category. Again, we see the epidemic curve rising.
This chart looks at HIV infections in women on a yearly basis. It divides women by birth cohorts, which means that it divides younger women from older women. We can see that in older women the HIV infection rate is declining, but particularly among younger women, we see very sharp increases.
So based on that, we arrive at a situation today where we have a fairly unstable epidemic, where the number of HIV infections may have declined from previous years. The number of infections represented, for instance, in the homosexual risk category probably has affected that decline. Fewer and fewer gay people are being infected by HIV. But if we look beneath that overall curve, we see that there are other populations in Canada that are becoming more and more at risk for this disease.
It's important to try to understand the current rate of new HIV transmissions, because if we look across some of the groups that I identified - women injection drug users; I could have shown you more charts dealing with young people, particularly young gay people under the age of 25, women, members of ethnocultural minorities - where all these groups are showing unsettling increases in annual HIV infections, it's clear that, going back to Jonathan Mann, what they all share is his experiences with marginalization and discrimination. These are people in society who fare low on the scale of social and economic advantage.
In the past, the way we've approached HIV transmission is, again, by taking a lifestyles approach, expecting that people can act in their own self-interest on the basis of accurate information. However, newer research in terms of determinants of behaviour and how behaviour is affected by some of these larger social forces is showing us that we don't exactly know how behaviour is affected. More research needs to be done to illuminate why so late in an epidemic, given all the information we have, there are still groups in our society that show alarming increases in the annual rates of HIV infection. I think Jonathan Mann tries to give us a clue by saying that we have to look at the larger social forces that perhaps prevent people from being able to make the choices we expect them to make and to choose healthier lifestyles.
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Leaving that aside for a moment, we want to move on to the other part of the point we want to make to you. We've talked about social marginalization being a risk factor for HIV transmission, and we have tried to present to you some data that support that. We now want to look at how being HIV positive itself leads to poverty and why that is so.
It's true that becoming HIV positive has a profound effect on economic prosperity, especially as symptoms appear, and some of that was addressed in the previous presentation. We live in a society where being able to work is key to individual economic prosperity, and the way HIV disease unfolds in a person's health, it is clear that it causes major interruptions to people's ability to work and therefore their ability to be economically prosperous.
Unfortunately, our benefit scheme for people who no longer can participate fully in the workforce is such that it conspires to keep people living with HIV/AIDS out of the workforce, and we have some examples of that to give you. The end result is that because of the system of perverse incentives, we change people who might otherwise be productive tax-paying citizens into dependent tax-receiving citizens, when if they had their own choices, they might not choose to do so.
As I think we heard Mr. Ménard say in the previous presentation, people living with HIV/AIDS experience cycles of sickness and health. It's one of those diseases where health status is rapidly fluctuating. People who have these kinds of conditions experience great difficulty in the kind of work and benefits interface. Our system is structured in a way that it's not very accommodating to people with this kind of health status, and our brief highlights six major areas of problems.
One has already been talked about in the previous presentation - the definition of disability. You heard the CPP representatives talk about ``severe and prolonged'' as their functional definition in assessing people who apply for disability benefits. Many other programs, particularly at the provincial level, use a ``permanently unemployable'' definition of disability in order to determine eligibility for benefits. I think this is one of the most important barriers to access to good flexible benefits for people with cyclical, fluctuating health conditions like people living with HIV/AIDS.
Another area that our brief addresses that throws up barriers is employer-sponsored group benefit programs. Universally, these programs have pre-existing condition exclusion clauses, which means that if you apply for a benefit program with a pre-existing health condition that the benefit company decides is too much of a risk for them, you cannot become eligible for private employer-sponsored benefit programs. In many cases this is a distinct and firm barrier to people deciding to participate in the workforce. Some would say the situation values the balance sheets of insurance companies over the human rights of the disabled and the chronically ill.
One of the aspects of group insurance coverage most sought by people with serious health conditions like HIV is coverage for drug costs, and the ability to have this cost covered or not covered is often the major influence in decision-making about whether someone continues to participate in the labour force or not.
Another area of benefits is employment insurance. People living with HIV often use the sickness benefit of employment insurance to give them income replacement during short periods of absence from the workforce.
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One of the emerging barriers to this program is the fact that it requires a longer period of labour force participation, which, given someone's fluctuating health status, is difficult to accomplish, and the fact that the median age of new infections for HIV is dropping to the point where people who might need this kind of coverage are too young to have had the extensive workforce participation that's necessary to qualify to receive them.
I won't talk much about CPP disability. In the previous presentation you heard a good deal of detail about that. You heard about some changes that were recently introduced to the program to try to allow for people with cyclical degenerative conditions, I think they're called, to try to integrate back into the workforce. Unfortunately, what you did not hear from them is how some of these new changes are inaccessible.
One of the main reasons is that, as you heard, there aren't a lot of people who receive CPP disability alone. There are people who receive CPP disability in combination with either private employer-sponsored programs or provincial social assistance programs. What's happened is that although the CPP rules have been made more flexible, the other benefit programs have not, so you can't access those changes to CPP without endangering your entitlement to these other sources of income.
The next and basically the sixth area the brief deals with is provincial social assistance programs. Many people living with HIV/AIDS now choose to go on provincial social assistance programs, and one of the principal reasons to do so is to get access to provincially sponsored drug programs in order to deal with the cost of drugs. Other reasons for going on social assistance are their not being eligible because of the particular health condition for disability programs, and becoming indigent and becoming eligible, as all Canadians are, for income support when there's nothing else to be provided.
Despite this, we do know the health needs of people living with HIV/AIDS cannot be met on current social assistance programs. The benefits do not account for the variety of health needs that people have when they have a complex condition like HIV/AIDS. Another thing worth mentioning is the fact that a lot of these programs are being tightened up and reduced due to the changes in transfer payments.
What we know and what's detailed in our brief is that the balance between food, shelter and medication for HIV-positive people trying to exist on social assistance often becomes perilous, because there's a series of very hard choices to be made between paying for medications that are not covered by programs or having an adequate diet.
The last area to touch on in this complex mix of factors that result in poverty for people who are living with HIV/AIDS - I've already touched on it briefly - is the cost of drugs. Our brief does deal with this. I think it's emerging as the biggest challenge to the economic well-being of people living with HIV/AIDS. People who want the most beneficial cutting-edge treatments can expect to pay upwards of $20,000 a year for drugs. It's clear that nobody wants to bear this cost, and I think we're heading for a crisis in this area in the near future.
Are we okay for time?
The Chairman: We normally give the witness a half hour.
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Mr. Armstrong: The last point I want to touch on briefly before I go through some of the recommendations with you -
[Translation]
Mr. Ménard: Mr. Chairman, I have to leave in 15 minutes. Could you ask Russell to wrap up so we can have time for a dialogue with him? Twenty minutes have gone by already. Since we do have their brief, it might be more useful if we could keep some time to discuss the issues raised in that document.
This presentation is very interesting, but I'm afraid that we won't have any time left to ask questions.
[English]
Mr. Armstrong: I think that's a good suggestion. We have a detailed brief. The last thing I'll say is that, in our brief, we try to provide a fairly broad analysis of the issue; however, what we try to do in the recommendations is to identify some concrete, immediate measures that could be taken to address the situation. It's clear that it takes a long time to fix the distribution of resources and deal with larger issues of health outcomes and poverty.
In an example of HIV/AIDS in our brief, we identify a lot of very concrete things that we could do now that would go a long way to mitigating the situation.
I'll conclude with that.
The Chairman: Thank you, Mr. Armstrong. We do have your brief. It is well done, well documented, and contains very pertinent information. Maybe we can cover some of that in our round of questions.
[Translation]
Mr. Ménard: If you agree, Mr. Chairman, and if my colleagues allow me to do so, I'd like to take the floor only once and use the full 15 minutes allocated to me, because afterwards, I will have to leave.
There are three fundamental issues in your brief. One, as I understand, you suggest to members of this Committee to press the Government to renew the National Aids Strategy. In your brief, you express concerns because the Minister has made no clear-cut commitments in this regard. In any case, the fight to keep people with AIDS from falling into poverty depends on a specific allocation of funds to the National Strategy. You insist that our report should include a very clear recommendation to that effect.
Then, there are two broad issues. You tell us that we should use the tax system. Right now, disability tax credits cannot be transferred between same-sex spouses. As I made a note of that, I realized that if we want to do a really good job, we should invite Revenue Canada officials to explain to us very clearly what is the cause of that continued discrimination. Maybe you could talk about that for a few minutes. In any case, you think that the tax issue is a real problem.
There is a third central element which, for me, is a very serious concern: it's the price of drugs. You go as far as asking Health Canada to strike a federal-provincial Committee to review the whole issue of the cost of drugs, as well as the protection problem. In your brief, you advocate compassionate access. You remind us that we are going to review the Patent Act in January 1997, and that it is important we keep these issues in mind.
To sum up, Mr. Chairman, I have but one question, which is going to please my colleague, and that is: What can you tell us about the tax system and the access to drugs?
[English]
Mr. Armstrong: As I mentioned in summing up, the brief has a number of concrete recommendations at the end of it. There are a number that touch on ways that, for instance, the current tax system could be adjusted to help people deal better with the costs of being disabled, particularly the costs of treatment and medical care.
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These issues were just recently studied extensively by the ministerial task force on disability. I would urge this committee to get hold of the report to see the extensive recommendations there about how to adjust, without substantial legislative change, some of the aspects of the tax system so they're more available for people with disabilities, particularly people living with HIV/AIDS and other chronic illnesses.
One of the particular items we mentioned here that often is not part of the discussion is the fact that, due to the definition of a spouse in the Income Tax Act, a lot of these credits are not fully available to spousal units of the same sex. Again, that is a good example of what I tried to point out about how the system as it is turns people who would otherwise be able to cope well independently with the costs of their condition into people who can't cope.
The fact that you can't within same-sex spousal units have the same transferability of expenses and tax relief for those expenses as people who are in opposite-sex units or even people who are in familial relationships, I think, is a fundamental inequity and something that could be adjusted fairly quickly.
In terms of the cost of medications, the Canadian AIDS Society and people living with HIV/AIDS are not alone in Canadian society at this point in pointing this issue out as a major concern in terms of our own personal health expenses and the amount of money that people in our country spend on health and health issues.
We give you examples here of what could be done for people living with HIV/AIDS. I know they just help fuel a larger fire - it's about to explode - about the fact that there are many Canadians who can no longer cope with the costs of medications to treat their illness, manage their health condition or continue to make themselves productive members of our society.
I think we have to ask ourselves: what is the choice to make? Do we try to cover the medical costs if somebody can continue to be full-time employed, reasonably successful, and a good contributor to the tax system, or do we deny them coverage of medical costs to then force them to be fully dependent on government assistance programs?
To me the choice is clear, but it has been a long time since we've seen this issue raised at the national level in any kind of political sphere. I don't think we have any direction at this point.
[Translation]
Mr. Ménard: Would you allow me one last question?
I know you are very much interested in the overall concept of humanitarian or ``compassionate'' access. I also know that the Canadian AIDS Society has a National Committee on drug treatments.
I also know that you follow very closely what the pharmaceutical industry does in this regard. You will recall that, following a motion I tabled here last February, I believe, a round table was held here on the issue of humanitarian access to drugs which have not yet been licensed for sale by Health Canada.
This whole issue is very complex and, as you are aware, Mr. Chairman, I'm going to table in a few days a private member's bill on the matter. I hope I will have the Government's support, but you know that nothing can be taken for granted.
Do you still feel that pharmaceutical companies - over all, I am not pointing the finger to any of them in particular - did not make the effort we could rightfully expect them to make - in terms of research and making drugs accessible to be used in emergencies - following the tabling of Bill C-91? How do you think pharmaceutical companies fare these days? Would you judge them severely, are you rather satisfied or are you asking yourself questions?
[English]
Mr. Armstrong: Dealing with the question of compassionate access for experimental drugs in a way that improves access to them and requires pharmaceutical companies to try harder will solve one important question in the whole problem of accessibility to treatments, but we still have to deal with what happens once those drugs are approved and they go on the market.
In our discussions around compassionate access, we dealt with drugs in the experimental phase, but we never went the next step further to ask what happens once they come on the market costing several thousand dollars a month.
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Who is responsible for assisting with that? In our discussions around encouraging pharmaceutical companies to provide compassionate access to therapies, we never dealt with the issue of how prices are established once the therapy is approved or what kind of controls are on the level of prices that are established so that Canadians can actually afford these things. Those are questions that remain on the table.
Certainly the patent protection provisions, as I think we note here, are up for statutory review next year. It's going to be one of the issues that we'll raise at the table there. Somebody has to deal with this. We have the knowledge and the technology to keep people healthy, but because of the price, people can't afford this. No one is willing to pick up that price.
Mr. Szabo: I was going through some of your recommendations, and I want to look at just one of them.
Before I do, I want to say that I found something interesting. If this had been the first time I ever listened to a presentation on this, I would swear that your emphasis should have been on what you referred to as the marginalized groups.
You showed the graphs. There were injection drug users, heterosexuals and women. You referred to them as ``unsettling increases''.
But in terms of the percentage increase, look at the absolute numbers: 80% of all new cases are homosexual men, 4.5% are from unknown causes, 4.5% are drug users, 4.5% are heterosexuals, and 3% are from blood and blood-related and products. I believe that's pretty well it.
I'm looking at the executive summary of your statements:
- In Canada, most of those who are testing positive for HIV are gay men, injection drug users,
women, youth, aboriginal people and members of ethnic -
I think you're marginalizing the whole discussion away from the problem of homosexual activity, which is a fact of where a lot of the focus has to go. If I went solely on your presentation, I would say that we should start spending more money on injection drug users, education and heterosexual sex. But that's not the case and you know it.
I want to address the second recommendation. It has to do with the comprehensive insurance coverage for those who are deemed uninsurable. I'm thinking of the presentation made by Dr. Hedy Fry at the Vancouver conference.
I think the figures have been shown by others, but when we get down to a full-blown AIDS situation, the costs are off the chart. It's $100,000 a year for Health Canada. It's $100,000 a year for an employer, and that could even double. There comes a point at which the costs of that just go right off the chart.
There is no amount of premiums that ever could be paid for someone who has a pre-existing condition. There is no amount of premiums that you could pay to fund that kind of stuff.
It really gets down to the fact that people who have full-blown AIDS will have to necessarily be cared for by other Canadians. That's what it really gets down to through taxation by governments. Nobody in this world is going to go into the insurance business to fund pre-existing conditions with the costs associated with that.
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We have to be a little more bold and blunt about the realities here, which means that when we get into this situation, it's going to be big dollars. The historic statistics are that if you contract HIV and you develop full-blown AIDS, the probability of you dying today is extremely high. I can't even talk about cures.
But do you not think, Russell, that maybe we really do have to be more realistic about the real facts and realities of the situation and of the costs of full-blown AIDS, and not try to suggest that we have runaway figures on heterosexual AIDS transmission or injection drug users? Those numbers are so minuscule compared to the problem with regard to gay activity.
That's where the true marginalization comes from. I'm not sure if it's really because they're gay. The marginalization occurs after the fact because of the disease. Is that not the case? I'd be interested in your comments.
The Chairman: Please allow the witness to answer all those multiple questions.
Mr. Armstrong: Yes, and at the end of it all, I'm not sure what the questions are.
Going back to the statistics you read out, I would suspect that those are AIDS statistics.
Mr. Szabo: They're Health Canada statistics that were presented to this committee.
Mr. Armstrong: At the national level, Health Canada only tracks diagnosed cases of AIDS. So I repeat my point about how a person becomes an AIDS statistic 10 or 12 years after they're HIV-positive.
The information I was trying to present to you in summary form deals with people becoming infected with HIV, which is a different story from the statistics that Health Canada presented to you.
In terms of the cost of caring for someone with AIDS, you're right in the sense that society bears the costs of that, just like we bear the cost of anybody else with a health condition. We have a publicly funded health system, and we don't determine eligibility for that system based on what your diagnosis is or how you got your particular condition.
The point we're trying to make in terms of saying that there should be a better universal insurance company for people in the employment market is the fact that there are certain benefits that you can have access to while you're employed that come through a group benefit program that will help slow down the progression of the disease. In the case of some of the newer therapies, these can almost stop the progression of the disease, provided you have assistance with the cost of the treatment required for that.
As for the figures you hear of around $100,000, the lion's share of that money is spent in the final stages, when someone is heavily symptomatic with the disease.
So the point we're trying to make is that if we invest a bit up front in providing assistance with some of the overwhelming costs of treating a health condition, we stand a good chance of preventing the onset to major symptomatic disease and, in the long run, probably saving some money.
Mr. Szabo: Prevent or slow? Prevent or defer?
Mr. Armstrong: At this point, we're at a bit of a crossroads. We almost believe that we can prevent progression, but at least we can slow it down. If the effect of slowing it down is keeping people as productive participants in the economic well-being of society, then I think we've gained immeasurably. The costs that we might incur to provide the benefits would be outweighed by the gain we would have by making people better able to participate.
Mrs. Ur: I thought it was rather interesting that when you made your presentation, you felt that HIV/AIDS clients weren't accepted for getting CPP, provincial benefits, social services, or whatever.
That doesn't happen to anyone else either, not just exclusively HIV/AIDS people. It happens to everyone. You can't get both. Your presentation stated that you felt you're being put aside or harassed by that particular...but that's the venue for anyone on a social services program or CPP. There's dollar-for-dollar deduction, and we can't afford to be paying both.
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In some of your recommendations you mentioned mandatory disability insurance plans. Isn't CPP basically a part of that, with the Canada Pension Plan retirement and the disability? That's basically what CPP is now, is it not? If you have x dollars of income you have to pay into the program. That's already there.
Mr. Armstrong: It's a bit more complicated than that. Everybody's entitled to a CPP benefit, which is the base amount and is fairly minimal.
Mrs. Ur: It's an insurance fund. What you pay is what you get.
Mr. Armstrong: Everybody, regardless of whether they work or not, can apply for CPP disability.
Mrs. Ur: No, they can't. You have to make contributions.
Mr. Armstrong: Wait a minute. The disability benefit is in two portions. There's a base amount, which we're all entitled to, and then there's an additional amount that is dependent on the contributions you've made and the number of years you've worked.
Mrs. Ur: No. When you apply for the Canada Pension Plan retirement or disability, it's based on your contributions. I know. I've been there.
Mr. Armstrong: I wasn't saying that people can't get access to both CPP and social assistance. What I was trying to say is that you heard about some of the changes to CPP that tried to make the program more flexible for people to try to re-enter the workforce and get off disability. What you didn't hear is how, as you say, people receive CPP in conjunction with other provincial benefits, for example, that top up that amount to provincial minimum income. Although the CPP portion is more flexible, that additional amount is not.
So you can't take advantage of the flexibility you get with your CPP benefit without endangering your entitlement to the provincial plan, because it's not flexible.
Mrs. Ur: There's only one taxpayer. It doesn't really matter who you're getting it from.
You also state here that you recommend the federal government establish a joint federal-provincial-territorial initiative to provide universal drug coverage for people with HIV/AIDS. Who is going to fund that? Where is all that money going to come from? Do we start segregating HIV/AIDS, heart patients...? My husband is a heart patient.
Mr. Armstrong: I'm not suggesting that we make a special deal for people living with HIV/AIDS. I'm saying that people with health conditions like HIV, which would include people with extraordinary medical costs.... If your heart condition is such that you have extraordinary medical costs, I'm saying there would be a social benefit to us if we had a program that helped you out.
Mrs. Ur: I've been with my husband with his heart attack, and while you can't put a dollar value on a human life, eventually we have to pay for this. Do you understand what I'm saying? These are all great ideas, but eventually there has to be some kind of threshold here; there has to be something we can work with.
Mr. Armstrong: Yes, and we're trying to make the case that there would be an economic benefit to the country for the expenditure of providing some assistance to people.
Mrs. Ur: But money isn't everything. There sometimes have to be lifestyle changes. Even with a heart patient they have to look at diet and exercise. It just can't be all put into medication.
Mr. Armstrong: I agree.
Mrs. Ur: I mean HIV/AIDS lifestyle changes.
Mr. Armstrong: I'm not suggesting that universal drug coverage will cure a health condition. I am suggesting that it would make it easier to probably deal with some of those other things if you didn't have to worry where the money was coming from to pay for the medications.
Mrs. Ur: Thank you.
The Chairman: With that, ladies and gentlemen, thank you very much for your kind attention. I thank the witnesses. It's a very comprehensive report.
We adjourn to the call of the chair. Thank you.