‘Not a done deal.’ What’s happening with Extended Health Benefits?

Some MLAs say the GNWT should pause a health benefits change affecting thousands of people over “confusion” and a lack of data.

Extended Health Benefits has been in the news for two years.

If the changes are introduced as planned in September, EHB will cover thousands of people who can’t access health coverage through work or other forms of government insurance, which the GNWT says is important.

People who need EHB will have their income tested before they can access coverage.

Most of them will need to pay a portion of the cost of their benefits – things like prescription drugs, dental treatment, eyewear and medical equipment – with the GNWT covering the rest.

Meanwhile, adopting EHB will involve scrapping the current Specified Disease Conditions program, which guarantees coverage if your condition is on the list.

The GNWT says the list wasn’t fair since you had to have one of a specific list of diseases to get that guarantee. But critics say it’ll be harder – and costlier – for people with chronic conditions to get the kind of comprehensive coverage under EHB that the Specified Disease Conditions program promised.

Regular MLAs say they don’t know who is actually going to benefit from this and how it’ll help the GNWT save any money. Patients say they don’t understand why they may need to pay more to treat chronic conditions.

On Tuesday, a committee of MLAs formally called on health minister Lesa Semmler to “pause” EHB’s planned September rollout.

Those MLAs said they had concerns about “the financial impacts, public confusion, and the lack of cost-benefit analysis data from the department regarding these changes.”

But Semmler has already told Cabin Radio she thinks there’s no chance of the policy changing, and it’ll be introduced as-is, on time.

“The program before had a gap. This is bringing an equitable program across the Northwest Territories that’s going to support all residents,” she said last week.

Here’s a Q&A to walk you through what we know so far.

I still have no idea what this program is really about.

It isn’t straightforward, but the basic answer is: The GNWT says there are just over 2,000 non-Indigenous NWT residents who don’t get health benefits from their employer and can’t access them any other way.

This program helps cover their costs. The GNWT has a webpage that explains EHB in more detail.

This sounds like a good thing. That’s a good thing, right?

That’s what the health minister says.

“This is going to provide services to individuals who normally would be low-income, that don’t qualify. People who work in jobs that don’t have any employer insurance,” Semmler told us in late May.

She pointed to new immigrants as an example. They might be working multiple jobs in the NWT without employer benefits, and EHB will cover a large portion of their costs for things like medical equipment and prescription drugs.

So what’s the problem?

For some people to get these benefits for free, the way other people have their benefits covered will change. Many will end up paying more than they do now.

The GNWT is using income testing to decide how much people who use EHB have to pay.

In theory, the lowest earners in the NWT will get their benefits for free. But some regular MLAs argue the income threshold is set ridiculously low.

As an example, in Yellowknife, the GNWT says anyone earning $31,135 or more per year will have to contribute some money to their benefits.

“This has been sold as a change to help folks who don’t have access to health benefits. No one is angry about that. That’s fantastic. Everybody has health benefits on September 1, that’s great,” said Kate Reid, MLA for Great Slave.

“But where I do have concerns is the fact that the threshold is just too low. It’s way too low. Even if you make a high five-figure salary, some of the impacts to the deductible and co-pay are going to be significant for residents.”

What do the people who’ll use this program say?

There are different levels to this question because how you use the program will change according to how much you earn.

People below the income threshold will get benefits for free. Others will see their existing benefits change, and they’ll be asked to pay a portion of their expenses in line with the new income guidance.

As an example, the GNWT’s website states that if you’re earning around $78,500 in the South Slave, you will need to pay a deductible of $700 on prescription drug costs, then pay 30 percent of your drug costs above that figure until you’ve paid $1,050 for the year, at which point EHB takes over and pays the rest.

If you earn $37,628 or less a year in the Sahtu, the GNWT says, you get free eye and dental benefits. Earn a cent more than that and, according to the GNWT’s website, those benefits are no longer available.

Laura Malone is a Yellowknife resident living with rheumatoid arthritis. She has chronic and sometimes debilitating neck pain, and that’s being addressed through medication.

On the Specified Disease Conditions program, she says she has coverage for “everything above what my employer’s healthcare offers, so I don’t need to pay for any of my medication – which is a huge help, because the total monthly cost of my meds is $1,450 or so without coverage.”

“I’ve actually had conversations with people who have said, ‘No, I don’t always get my meds because I can’t always afford it.’ And so those supports have really alleviated that stress of having to worry about paying for the meds,” Malone told Cabin Radio last month.

What will happen when EHB rolls out to replace Specified Disease Conditions?

Doing the math, Malone says EHB will ask her to spend four percent of her net income for the year on medication before the GNWT steps in to cover the rest. (Her employer already covers 80 percent of medication costs, so EHB would be used to cost-share the remainder.)

“It’s going to take about nine months of me paying out of pocket before I will get that assistance again,” she said. “The cost will go up $2,300 for me per year.”

That’s the point of income testing, isn’t it? Figure out who can pay?

“I do agree with having a fair, equitable system for everyone,” said Malone. “I do not agree that removing life-saving medication coverage for people with really serious illnesses is the right way to go about that.”

Frame Lake MLA Julian Morse wonders how the program will come across to NWT residents who discover they’re paying more.

“The NWT is already a difficult place for persons with disabilities to live. It’s already a difficult place for persons suffering from chronic conditions to live. Do we want to tell them, ‘We’re not going to help you any more?’ And then what?” Morse asked.

“If I was one of these people, I would consider whether I should move south where I can receive better access to services, if I’m not receiving a benefit that I wouldn’t get in the south.

“In the south, my cost of living is going to be lower and I’ll have closer access to services. Why would I stay in the Northwest Territories? I think that’s a very fair question to be asking but, as politicians, we should be looking at how can we attract retain residents to our territory.”

Malone said: “I’m happy to pay more as someone who is fortunate enough to have a stable income, but I want it to actually be designed in a way where it’s going to help people who make less money.

“The way it’s designed right now, I don’t feel like that is going to be the case. I feel like it’s basically making it impossible for anyone to access this assistance.”

So what do people below the income threshold say?

Regular MLAs we spoke with said they couldn’t find anyone who falls into that category to ask them. If that’s you, get in touch with us as we’d like to hear from you about these changes.

Those MLAs argue that if the territory is making some people pay more, where are all the people who the GNWT says will benefit as a result?

In 2022, then-health minister Julie Green told Cabin Radio: “Our health system has a $190-million deficit that is increasing by about 20 percent a year. At some point we have to stop giving things away to people who can afford them, and this is that moment.”

“This whole initiative was originally brought forward ostensibly as a cost-saving measure,” said Morse last month.

“Then it became a measure by which we are extending benefits to this group of people, whoever they may be. But what I’ve started to question is: Who is that group? Are they asking for coverage? I haven’t actually heard from anyone who defines themselves as being within that group, that says, ‘You know, Extended Health Benefits coverage is what I need.’

“What I have been hearing is from people who fall under the existing program – people with chronic illnesses, people with diabetes, people facing cancer treatment, people who really need extra help. Are we going to save very much money? And is the best way to save money in the healthcare system to put it on the backs of people who need the most help?”

That seems like a fair question for the minister.

“We’ve heard this,” said Semmler, “but it’s going to provide services to those 2,200 people who have had no access – no access to medical supplies, no access to prescription supports, no access to dental.”

“In the long run,” the minister added, “when they don’t have those services, they end up not accessing services and not getting the medication that they need. Then they end up in our emergency department, which is going to cost a lot more.”

Wasn’t there a big public engagement on this?

There was.

A survey about the changes before they were finalized got 729 responses – a huge number for a territorial government survey.

Of those, 51 percent said they either disagreed or strongly disagreed with the proposed changes. Forty percent agreed or strongly agreed overall.

The GNWT says it listened to feedback, removing a proposed requirement that residents “purchase third-party insurance and exhaust its drug benefits” before being eligible for EHB.

Malone says there was nowhere near the change she expected to see, given the strength of feeling communicated by some people through their feedback.

“I don’t think that the message was heard from those who are really going to be impacted by the changes,” she said.

What happens now?

We are in budget deliberation season, which does give regular MLAs some power. The budget can’t move forward without some regular MLAs voting to support it.

Asked if he thought the changes were certain to go ahead, Morse said: “It’s absolutely not a done deal.”

“I’ve been engaging with constituents on it and have not heard from a single person who’s supportive, so it’s pretty easy for me to decide where I stand as a representative,” he said.

“I don’t support the policy as it is. Either the GNWT takes a step back, re-evaluates what it’s doing and comes forward with a proposal that people can stomach, or it simply drops the initiative.”

Asked if there was any chance of EHB being delayed or abandoned, Semmler replied with one word: “No.”

What changed on Tuesday?

Tuesday’s formal request for a pause from a committee of MLAs gave their concerns a higher profile but didn’t appear to change anyone’s position.

“The committee urges the minister to pause the changes until the issues with the proposed changes to the program are resolved,” a committee of MLAs wrote, calling for a “clear and comprehensive understanding of the financial implications” alongside better public messaging.

Specifically, the committee wants the GNWT to tell it what would happen if income testing was removed and what other options are being considered.

Semmler quickly responded with a written statement that made clear she will not entertain a pause.

“Leaving those 2,200 residents – many of whom are low-income – to go without extended health benefit coverage is not something I’m prepared to do. It is unfortunate and disheartening that the people who need these benefits the most, and who this new policy is designed to help, seem to have been forgotten in much of this discussion,” she wrote.

“Providing equitable access to these benefits for all residents will address barriers to preventative care and early medical intervention, which can greatly reduce healthcare costs later in life.

“Using tools such as income testing as part of the renewed program helps us make sure that those who need the most support get it based on their financial situation. This doesn’t just keep our system equitable – it also helps keep it sustainable.”

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