Proposition 54K1838

Projet de loi portant des dispositions diverses en matière de santé.

General information ¶

Submitted by

MR Swedish coalition

Submission date

May 18, 2016

Official page

Visit

Status

Adopted

Requirement

Simple

Subjects

administrative formalities pharmacist doctor labelling medicinal product health policy health care smoking aesthetic surgery social security tobacco veterinary drug public health health insurance

Voting ¶

Voted to adopt

CD&V ∉ Open Vld N-VA LDD MR

Voted to reject

PVDA | PTB

Abstained from voting

Groen Vooruit Ecolo LE PS | SP DéFI VB

Contact form ¶

Do you have a question or request regarding this proposition? Select the most appropriate option for your request and I will get back to you shortly.

Discussion ¶

June 9, 2016 | Plenary session (Chamber of representatives)

Full source

The rapporteurs are Mr. Piedboeuf and Mrs. Thoron.

I am referring to the written report.

I do not see the Minister.

For the information of the groups, the Minister is abroad and therefore absent. Being a co-signator of a small part of this text, I will try to represent it.

Mr. Minister, dear colleagues, just a few words to justify my group’s abstention on this bill containing various health provisions. These are extremely technical measures that have been presented to us and for which we unfortunately did not have all the precise answers to the questions raised in the committee.

First, as regards pediatric conditions and the possibility that is given to the King to fix a particular period allowing to extend to less than eighteen years the refund of a specialty already included in the list of reimbursable specialties, if it is already refunded in the more than eighteen years in the same indication, giving a faster treatment to beneficiaries under eighteen years is obviously interesting. However, we still do not know what conditions must be fulfilled in this procedure and in what context it could be applied.

Indeed, this new indication for children should be subject to the same attention as another extension of indication. It is not because a medication is allowed for children that it is the best treatment option available. There may be other treatments that are less burdensome for the child or cheaper for health insurance. It should also be noted the importance of encouraging pharmaceutical firms to conduct more studies on specialties concerning children in particular.

Secondly, in relation to the changes made to the Health Care Insurance and Compensation Act, in order to allow the establishment of the oral care routes provided in the Dento-Mutualist Agreement 2015-2016, the primary question we ask ourselves and we still ask ourselves is whether this modification, i.e. the fact of increasing the personal quotas in dentistry, is of general scope or whether it will only aim to allow the establishment of these care routes.

Furthermore, if we understand the importance of oral care tracks, we remain convinced that this differentiation in the reimbursement of benefits among those who follow this route and those who do not follow it will not be effective among disadvantaged audiences, among the most fragile audiences.

By increasing the personal quota of these patients for priority benefits if they have not consulted a dentist the previous year, you will undoubtedly only accentuate the gap that already exists in this area. Because you know how difficult it is for these people to go to the dentist. Financial access to dental care remains complicated for many citizens.

Other measures should be considered for the most disadvantaged public. The compulsory paying third party is obviously an important track. There are others, but for now, we do not see any progress in this area.

Third, the new exemption to decrease by 7.5% after eighteen years or when a biosimilar arrives for long-acting insulines appears unjustified to us, especially since Ms. Minister De Block had previously granted a reduction exemption of 19%, which is valid for all medicines and not only biological. The minister justifies only the new exception on a measure that specifically targets the biological by the fact that they have the first, which targets all medicines. This is not a real motivation. Long-acting insulins cost twice as much for the same volume as short-acting insulins, with comparable methods and therefore comparable production costs. With the budget surpass announced for 2015 in medicines, it seems to me that these decisions, gifts I should say, should be more thoughtful.

Finally, a last word on the fight against tobacco. The European Directive was to be transposed in May. The provisions you have inserted in this project with various provisions in this framework are no longer minimalist. It is little to say. We hope that it is because it has been agreed that we will be able to have a very wide debate in the Health Committee on this important issue and that you want to let us move forward in this context. Thank you for your attention.

Before I specifically emphasize the dossiers that are important for our group in the context of this bill containing various provisions, I would like to correct something that the previous speaker has completely misinterpreted or understood, in particular regarding the extension in connection with the indication pediatrics. The Minister has also clarified this point in the committee. The previous speaker argued that without studies there would simply be an expansion of the target audience, which, of course, is not the case. This is never the case. The point is that the procedure, which now takes seven to thirteen months, will be shortened, of course based on studies. That is always the case.

You advocate that firms should be more encouraged to investigate their indication for children. This is precisely the purpose of the bill, which, for example, also includes agreements on price drops, which are present at the moment when the indication is extended to children. As a result, it is often less interesting for firms to invest in them, even given the long procedure. It is just the combination of shortening the procedure and removing the price drops at an indication for children that will facilitate access to important drugs, including against cancer and psoriasis.

In the proposed bill containing various provisions, our group also considers the dossiers on oral care, on medicines shortages and on the use of antibiotics in animals very important. We are of course also very satisfied with the implementation of some of the agreements of the pact with the pharmaceutical sector, such as the accelerated access to medicines, including for children, as I have already clarified. This is of course beneficial to the patient.

The measure related to the oral care pathway is controversial, even though it is intended to encourage individuals to have their teeth checked regularly. Various misinformation was sent to the world from certain angles, but only by the announcement of the measure were citizens encouraged to have their teeth checked. This shows how positive that measure is and why we advocate that it be put into practice as soon as possible.

We hope that the efforts will not be limited to this measure, but will also be spread, for example, to the very important group of diabetic patients, of which only four out of ten go to dental examination annually, while they are equally much more susceptible to dental problems, and to children.

Figures show that the latter group also has major problems in this area, especially south of the language border. There are still efforts needed. More should be invested in preventive care, which has been shown to be cheaper in the longer term and much better for the well-being of patients and society.

With regard to the shortage of medicines, we in the committee welcomed the new measures. We hope, however, that further steps will be taken. We see much salvation in a holistic approach, of which this bill may be the beginning for us. As many stock breaks as possible should be avoided by clear arrangements on the refund procedure. Certainly vital medicines should always be available.

In order to prevent stock breaks, there should be a clear inventory, with the obligation to report the penalty of a fine. If there is a shortage, a solution should be found as soon as possible. Not only do pharmacists need to have more room for movement to use alternatives. Those who caused the deficit must also be held accountable: they must pay the cost of finding alternatives.

We also see salvation in an ultimate stick behind the door. A clear and coherent approach to stock breaches needs to be developed, ⁇ when they occur regularly.

The legal basis for inventory of the use of antibiotics in animals, we find a great step towards a solution to the problem, which often reaches the media.

We have said very clearly that this is a first step for us. We still have a lot to do, for example, with the introduction of mandatory indication registration. Furthermore, the veterinarian, who should play a central role in the registration and not the farmer, should no longer correct entered data.

Finally, I want to talk about the procedure for medical devices. We welcome the initiatives to incorporate the evidence-based medicine approach into the entire policy. We think that is a good step. Of course, we will fully support the bill.

During the general discussion in the committee, I have already expressed my appreciation for the fact that the present bill contains a number of provisions for the implementation of the Pact with the pharmaceutical sector. Our country is a champion in clinical research in Europe and we are among the best in the world. MSD and Janssen Pharmaceutica carry out 90 percent of Phase 1 clinical trials in our country. Pfizer has its own laboratory. Those clinical trials are not only important to keeping pharmaceutical companies as an economic player in our country or to serve pharmaceutical companies, as the committee suggested. No, domestic clinical trials are ⁇ important for patients. It also means that our patients will have faster access to innovative medicines.

In order to maintain that position, the Minister has entered into a pact with the pharmaceutical industry, including not only financial measures, but also a range of measures to make procedures more efficient and faster, to make medicines more readily available to the patient, as well as biobanks with attention to the consent of the donor, taking into account the use of transformed material. Therefore, it is also important to say that with the draft the minister fulfills a significant part of its commitments and we can only support that as a group.

Yoleen Van Camp has already stated that the non-availability of medicines is a problem in our country. I asked a question about it to the Minister some time ago and she then replied that there was already a reporting point for unavailability. With the draft, our Minister also tightened the mandatory notifications, because also a temporary unavailability must be ⁇ . I am pleased that wholesalers will also be required to report, as part of the problem naturally arises in parallel trading. Only if we have a good view of the unavailabilities can we work on the remedy. From our group, we are, of course, looking forward to the measures taken to substantially remedy the problem and, not least, to the results that will be achieved by the task force at European level.

With this legislation, we also create a legal basis for a follow-up system at the FAGG for antibiotic use in animals. Although this is a matter of agriculture, it is also a matter of public health.

Antibiotic resistance, which in our country is very high and poses a danger to public health, has to do with the excessive human use of antibiotics, but also with the too generous use of antibiotics in animals. The measure is not coming too early and I am pleased that the government is working on it. I hope that the implementation of the measure and the control of the implementation will be monitored very closely. There is a lot at stake here.

We are pleased that the foundation is also laid for long-term dental care. The increase of the brake fee from 10 % to 20 % for rightholders with an increased benefit and from 25 % to 40 % for ordinary rightholders who did not have a consultation with the dentist the year before may appear in an initial phase as unaccountable. However, it is essential that we encourage people to conduct an annual consultation. This is necessary because today only 60 % of people go to the dentist annually, even though in the past many measures have been taken to enable people to consult the dentist. I mean the full refund of the oral examination, the removal of dental stone, the filling or restoration of teeth, the treatment of dental nerves and the pulling of teeth in children under 18 years of age. The limited results of those measures made other measures necessary, as only regular visits to the dentist can ensure a healthier tooth.

Finally, I think that all-in RIZIV funding for all care-related costs in the forensic psychiatric centers is a good thing given the vulnerability of the people who reside there. It shows that the government takes the situation of interned people at heart. Open Vld will therefore fully support the design.

Mr. Speaker, Mr. Minister, Ladies and Gentlemen, I will make a relatively short general speech, since the discussions have already taken place in committee. I would simply like to point out that the project that is submitted to us brings together, as traditionally, different varied but indispensable measures in the field of health care. It also introduces administrative simplifications. In this regard, I agree with Mr. Senesael who also talked about the technical aspect. This project also concrete accelerations of procedures for the benefit of the patient. It is considered, for example, as has been said, to reduce the time between the moment of the decision to refund a medicine and the realisation of the measure.

I also point out, obviously with satisfaction, the new procedure aimed at reducing the waiting period between the granting of authorisation in the context of a pediatric condition and the refund of medicines that have already been refunded for adults. It is true that at present, a company that wishes to market a pharmaceutical specialty must first develop it for adult patients, and only then will it eventually be able to adapt it. Some doctors already prescribed this medication to children with the consequence of a lack of refund and the responsibility of prescription. Through this new approach, children will be able to reap a real benefit.

I also support the introduction of a system of comprehensive financing for the reimbursement of the costs of care in the legal psychiatric centres and I recall in this regard, as I said in the committee, that the lack of adequate reception for interned persons who are currently in prison must be stopped. All our citizens deserve to receive quality care at the right time and above all at the right place.

Articles 19 and 20 relate to the increase of moderator tickets for dental care. This is a patient accountability measure that aims to encourage people to undergo dental checks each year. This is a measure from the National Dento-Mutualist Commission in the Tariff Agreement 2015-2016. We can only subscribe to it.

Article 31 provides for the obligation to notify the unavailability of medicines, even temporarily. This positive measure will anticipate possible problems in the field, when a drug may be exhausted. I gave a very specific example in the committee. It is true that in some cases there may be abuses. We therefore have here the will to have a great collaboration between the actors and above all to ask them to take their responsibilities. This is also an important point that needs to be raised.

I will end by highlighting the new transitional measures for pharmaceutical and technical assistants, which were expected by the sector. This was also stated in the committee. Now there are provisions and I think the whole sector will benefit. These are the various remarks I would like to make in relation to the current debate. It is clear that the MR group will strongly support this bill. I thank you.

Mr. Speaker, Mr. Minister, colleagues, we discussed this draft containing various health provisions several weeks ago in the committee after it was submitted to us. In our view, this bill contains a number of technical issues that will be resolved in a positive way and a number of complex procedures that will be simplified and made more transparent. To that point, bravo.

Despite this good news, there are still two major points in this bill on which we fundamentally disagree.

The first concerns the adjustment of the brake money ceilings for dental care. This is in line with the measure established in the agreement between dentists and hospital funds. The brake fee when visiting the dentist is therefore sensibly increased for those who do not go to check at least once a year. I fully agree, our group fully agrees that we should try to encourage people to go to the dentist and to have their teeth checked on a regular basis, but this is really not done by punishing them.

For a lot of people today, the threshold to go to the dentist is already high, not so much because of the initial costs for that first visit, but because of the fear of the costs if something is wrong. We all know that oral care is not really cheap. If the financial threshold for the first visit still rises, then the most vulnerable in our society will be cut off first. The measure means that anyone who has not visited his dentist in the past year or forgot to visit his dentist in the past year pays the following year 14 euros in brake money instead of 7 euros. We are firmly convinced that this measure punishes just those people who already have very difficult access to dental care.

Mr. Speaker, Mrs. Jiroflée, these are the untruths that I have already mentioned. This is not entirely correct. You should be informed about the facts. It is about that those who have not been on check with the dentist in the year before, will have to pay a higher brake fee: not for a regular check, not for the routine examinations, not for the routine interventions, but if then it turns out that there have been problems that could have been avoided by an annual visit.

For example, we are talking about the larger procedures such as a tooth extraction or a cyst. It’s not about things like checking the teeth and removing plaque. That is not correct at all.

You notice that the financial barrier is raised and that people don’t go to the dentist because they don’t dare. I am very interested in what you propose. For example, for children, the visit to the dentist throughout the line is free. Nevertheless, we see that the problem of non-compliance with the annual visit to the dentist is much worse.

So what is your alternative? What exactly do you suggest to encourage people to go to the dentist?

Mr. President, Mrs. Van Camp, you know our position on this subject. Whenever the price for a visit or the brake money is raised, people will be discouraged. Certainly people in a vulnerable situation do not always understand how the system is in place. People will be scared.

What we are talking about is the following.

We also want to encourage people, especially those in a vulnerable position, to go to the dentist. For us, however, here too much of the stick and too little of the root is used. Anyone in education will tell you that people should be encouraged to get positive results. These results are not obtained by punishing people.

That is why we do not agree. We all benefit from a well-treated tooth. However, we are convinced that these vulnerable people will be cut off.

Therefore, we will submit our amendment on the third-payer scheme to the dentist again.

A second point that we would like to draw attention to here is the adjustments relating to tobacco products.

With the extension of the definitions that also include e-cigarettes and the like, we agree entirely. This is a good measure for us.

The venin, however, is here once again in the tail, namely in the very last article of the present draft, in which the labelling of tobacco products is adjusted to bring them into conformity with the European directive.

Mr. Minister, I hope that you communicate to your colleague that this is really a missed opportunity. It was the opportunity to start with the so-called plain packaging, in which the cigarette packages are removed from all advertising and hippe imagery of cigarettes to which young people are so sensitive. We also all know that it is those young people that we should try to stop smoking because they are the most likely to become addicted and remain.

Meanwhile, the system of the neutral package has proven its usefulness in several places.

That the Minister lacks this opportunity and absolutely wants to wait until 2019 to start with the plain packaging, is, in our view, a lack of format.

In summary, I can say that the design contains a number of good technical adjustments and two material shortcomings. We will abstain from the vote.

Mr. Speaker, Mr. Minister, dear colleagues, this bill containing various provisions includes interesting measures that we will support.

Following our discussions in the committee, Mr. Minister, on policies to better control the use of antibiotics for animals in order to reduce their consumption, given the risks of antibiotic resistance, we have concluded that we should support this measure, which we consider to be positive.

Other provisions of the bill under consideration are also interesting. However, various questions remain unanswered while certain provisions may appeal. Thus, the Minister did not respond satisfactorily, on the occasion of the exchanges we had with her, to our questions regarding the conditions for the management of certain measures taken to facilitate access to medicines;

It is true that the purpose of the provisions that are presented to us is to facilitate, to speed up access to certain medicines, to certain refunds. However, the methods used are sometimes questionable. Thus, changing a list of medicines authorised or not and publishing, a posteriori, through a decree, the amendment of that list rather than making it compliant with a decree constitutes a first that opens doors to how to authorize and negotiate directly with pharmaceutical firms without ensuring that the regulatory and regulatory role will effectively be fulfilled by the INAMI bodies. It also raises the question of taking arrests or taking legislative measures in parliament, when this proves mandatory.

The text also sacralizes the non-transparent negotiations between the Minister, the SPF Public Health and pharmaceutical firms, as part of the agreement between the pharmaceutical industry and the Minister of Health “for the benefit of patients” – in any case, this is what is stipulated in this pact – but also and above all for the benefit of pharmaceutical actors who develop innovative products and new molecules. In this regard, the text seems to us to be too positive, too focused on self-control and too little on the need for politics to assume its role.

Two points are really problematic. The first concerns the measures taken to penalize the person who does not regularly consult the dentist to have access to the moderators ticket as low as possible. The device penalizes financially the person who is not sufficiently responsible. This is placed as part of the desired oral-dental care journey.

We find that there is a deviation, a deviation from the concept of care journey. The path of care is not to define a straight line from a point A to a point B for the person who has a health problem, here in this case a need for dental care. If the person deviates from this line, he is subject to penalties. In some cases, it will be excluded from certain care. In others, she will be punished financially under the pretext of accountability.

But a journey of care is not that. This means considering the person as a whole, including the different stakeholders concerned by the different care they need and, between the patient and these care providers, considering how to give the patient access to the necessary services. It is well known that oral-dental care is the most difficult thing in health. The impoverished person, the one who has a poor self-image, who has no confidence in himself, who has no confidence in others, is often among the poorest people. We have noticed it. These people do not go enough to the dentist. They come from disadvantaged socio-cultural environments. These people will be punished because they do not go to the dentist.

What should be done? In any case, take pro-action measures towards these people. It is necessary to play a proactive role and adopt behaviors that "will go looking for them." You need to be able to better inform them and make sure they feel confident to visit the dentist. It is not necessary, of course, to penalize them or strengthen the image that they make of the price of dental care: they are expensive. They are generally expensive, but these people benefit from rates sometimes tailored to their income. However, they are convinced that such care is too expensive and thanks to your project, we are further reinforcing this idea.

I think the opposition is not listening to what Mrs. Van Camp just said about dental care. I will repeat this very briefly.

Do you think that one punishes a patient if one makes sure that he can go to a dentist every year for a check, and that he, if problems still occur, receives a better refund, rather than a patient to say that he does not have to come to a check every year, and if after twenty years his teeth fall out, then one also expects the government to pay for this?

Do you think this is good for the patient? You must give a sign to the patient. The government does not only pay back to pay back. At first, this is not an austerity measure. We want to ensure that every patient who walks around here in this country has a healthy tooth. You call it penalization, I think that’s about it.

These are theoretical arrangements taken by people in an office. Not being on the field, they do not see that this goal that we all pursue, namely regular visits to their dentist, does not work in fact! You say it yourself: when care is free, people don’t go to the dentist. What oral dental care represents is not interpreted in the same way by everyone, which makes some people not go there. You have to work to help them get there, you have to take steps to ⁇ the goal, but you have to do something other than what you do. We have already experimented with the removal of refunds as well as penalties; it has not worked. This does not hold people accountable. It is not responsibility that is at stake, but trust!

Also that is really thick sewer and testifies to a lack of file knowledge. This measure does not even come from the government, but was proposed by Dentomut. Who is in it? The dentists themselves, yet people who work with people on the ground daily and provide dental care. Do you not think?

Secondly, you and the previous speaker are only talking about the opportunity groups, while this arrangement does not apply to the increased respondents, so please do not proclaim any more falsehood about this too.

I am a sociologist of education. Sociological research shows very clearly that when one works with people in poverty, rewarding works much better than sanctioning. A lot of research has been done on this.

We can read the level of poverty from the teeth. I ⁇ don’t want to polarize, but the way in which some groups in our society are sensitized and how people go to the dentist can go in a different direction, especially for children.

Ik moet in herhaling vallen. Ik zei net, maar u luistert precies niet, dat dit niet geldt voor mensen met een verhoogde tegemoetkoming. Wat u zegt, houdt dus totaal geen steek.

Het houdt wel steek en ik sluit mij aan bij mevrouw Gerkens en mevrouw Dedry. Iedereen die al met kansengroepen heeft gewerkt, weet dat een moeilijke regelgeving ertoe leidt dat mensen uit schrik niet gaan. Bovendien bereikt men met straffen het omgekeerde effect.

Het is niet omdat het niet geldt voor mensen met een verhoogde tegemoetkoming. Mensen begrijpen het niet! Zorg dat mensen op een goede manier naar de tandarts kunnen, dat kinderen geen achteruitgang boeken en niet achteruit worden gezet in hun opvoeding, dat kinderen als volwassene met een mooie mond vol tanden kunnen gaan solliciteren.

Ik heb de indruk dat mevrouw Van Camp en mevrouw Somers nog nooit een groep arme mensen met kleine kinderen van dichtbij hebben gezien.

Mijnheer de voorzitter, ik heb redelijk wat ervaring in de sector en ik kan u verzekeren dat het inderdaad niet alleen gaat over de centen. Het gaat over een totaalpakket aan waarden en ook angst voor een aantal zaken. Men ziet bij families die in armoede leven, maar ook bij families die net boven de armoedegrens leven en andere waarden of andere percepties hebben over de maatschappij, een zeer grote angst om naar een tandarts te gaan. Men gaat pas naar een tandarts als men pijn heeft en het dus eigenlijk al te laat is. Dat is de dagelijkse realiteit.

Het aantal valse tanden en valse gebitten dat ik als OCMW-voorzitter heb laten betalen, kunt u zich gewoon niet indenken.

Mijnheer de voorzitter, in de commissie hebben wij het daar ook over gehad. Ik vind het bijzonder jammer dat wij nog geen stap verder zijn geraakt. Het probleem is ook dat de gezondheidskloof alleen maar groter wordt, doordat het aantal tandartsen dat zich deels of helemaal niet meer conventioneert, alleen maar toeneemt. Dit bleek uit een antwoord van minister De Block op een vraag die ik haar stelde. De cijfers van het RIZIV zijn duidelijk.

Dit gaat ten koste van de mensen die niet goed weten wat het verschil is tussen geconventioneerd en niet-geconventioneerd. Vooral de armere bevolkingsgroepen kunnen de tandarts niet meer betalen. Dat is pas de gezondheidskloof organiseren.

Monsieur le président, c'est une décision de la Dento-Mut, dont on ne peut dire qu'elle soit composée uniquement de gens dans des bureaux. Ils connaissent assez bien la réalité de terrain. Il faudra être vigilant pour voir la manière avec laquelle les enfants, les adolescents voire les adultes vont consulter leur dentiste en temps et en heure. Il est dommage que la ministre de la Santé ne soit pas là car je voudrais vraiment plaider auprès d'elle et du gouvernement pour qu'on réalise une évaluation régulière des effets de ce mécanisme.

Je peux entendre "peut-être qu'on sera efficace" mais il faudra être attentif au fait qu'on ne soit pas plus délétère pour un certain nombre d'enfants, d'adolescents ou d'adultes et qu'on les éloigne encore plus du circuit et du suivi régulier par un dentiste, ce qui risque de se payer très cher au plan qualitatif pour les patients, mais aussi au niveau de la sécurité sociale car les soins seront beaucoup plus lourds et seront remboursés de toute façon.

Je plaide donc pour une évaluation régulière avec la Dento-Mut pour qu'on puisse véritablement s'assurer qu'il n'y a pas d'écueil et d'effet délétère de ce dispositif. On peut croire qu'on fait le bien mais parfois on fait le mal sans le vouloir, d'où l'importance de réaliser cette évaluation.

Mevrouw De Coninck, u zegt, vanuit uw ervaring in het OCMW, dat wij ons niet kunnen indenken hoe dikwijls een gebit moet worden terugbetaald. Daar gaat het juist over. Die mensen moeten vroeger naar de tandarts gaan.

(…)

Maar ze gaan niet! Zorg er in een OCMW dan voor dat mensen gestimuleerd worden. Tandzorg onder de 18 jaar kost niets! Tandzorg voor kansarmen kost niets. De basis kost niets, ze kunnen elk jaar gratis naar de tandarts gaan, maar zij gaan niet. Er zijn ook wel grenzen.

Ik treed mevrouw Fonck bij. Dit moet hier zelfs niet gezegd worden, maar in het kader van goed bestuur worden elke nieuwe methode, elke nieuwe procedure en elke nieuwe ingreep op tijd geëvalueerd. In een goed bestuur is dat een basisregel.

Ik begrijp dat u op die manier reageert, want u bevestigt alle vooroordelen over kansarmoede die in de maatschappij leven. Wat is het verschil tussen iemand die in kansarmoede leeft en iemand die niet in kansarmoede leeft? Dat is het gebrek aan langetermijndenken. Men gaat dikwijls maar naar de tandarts als men pijn heeft en als er een tand getrokken moet worden. Dat is dikwijls de realiteit. Zij moeten veel vroeger gaan, maar waarom doen zij dat niet? Omdat zij niet inzien dat een goed gebit belangrijk is voor de rest van hun leven, ook om te solliciteren en presentabel te zijn. Dat is zo voor veel zaken. Zij gaan ook dikwijls naar de wasserette omdat zij de middelen niet hebben om een wasmachine te kopen, hoewel dat op lange termijn goedkoper is. Dat zijn maar enkele dynamieken die spelen.

Via het onderwijs, via de school en via contacten met ouders en organisaties kan men daarover sensibiliseren.

Monsieur le président, je serai bref. J'entends les deux opinions. Étant aussi en charge de l'Intégration sociale, j'entends certaines remarques et points de vue. C'est un des éléments à propos desquels Mme Maggie De Block avait été informée et interpellée en commission. Elle souhaitait marquer son accord quant à une évaluation, comme Mme Fonck vient de l'évoquer, de sorte que l'on puisse alors revenir le moment venu en commission pour voir quels sont les impacts souhaités et éventuellement non désirés de la mesure concernée. Ainsi, nous pourrons ensemble partager les constats le cas échéant.

Monsieur le ministre, je suis heureuse d'entendre cette réponse, parce que ce sera indispensable face aux craintes que plusieurs ici évoquent, vu la difficulté qu'ont toute une série de personnes à se rendre chez le dentiste et vu les pénalités qu'elles risquent de subir, et donc leur éloignement encore plus grand des soins dentaires. Par rapport à cela, c'est important que l'impact de mesures puisse être examiné.

Mais c'est aussi important au vu des intentions qui traversent ce débat. Une telle agitation pour démontrer qu'il faut quand même être suffisamment responsable de soi-même en allant régulièrement chez le dentiste traduit vraiment tout ce qui traverse les politiques que vous menez tant en matière santé qu'en matière sociale. C'est considérer que celui qui ne fait pas suffisamment, qui ne démontre pas qu'il a suffisamment de mérite, se fait pénaliser ou exclure.

C'en est un exemple, mais il y en aura d'autres dans d'autres dispositions. Parmi les solutions, il y a notamment de rendre confiance aux gens, d'arrêter de vouloir les exclure et peut-être aussi de cesser de les appauvrir via certaines dispositions prises depuis quelques années.

Je voulais intervenir sur un dernier point relatif aux mesures sur le tabac. Je suis mitigée, parce que nous attendons la transposition de la directive européenne dans ses diverses composantes qui devait avoir lieu au plus tard au mois de mai de cette année.

Les parlementaires de la commission de la Santé publique ont déposé des propositions de loi et de résolution depuis plus d'un an. Nous essayons d'y travailler avec la ministre, mais nous ne sommes pas encore parvenus au terme. La ministre avait pris l'engagement d'élaborer des dispositions contre la consommation, la publicité et la commercialisation du tabac sur la base des textes déposés en commission. C'est pourquoi je me plais à répéter sa réponse. J'espère que son collègue l'aura bien entendue. Nous nous sommes abstenus sur les amendements déposés, y compris ceux de Mme Fonck qu'elle redépose aujourd'hui, parce que nous souhaitions que s'organise véritablement ce travail collectif en commission.

Au-delà de cet aspect, il est quand même scandaleux qu'en ce mois de juin, le chapitre "Mise en conformité avec la directive européenne" du projet de loi portant dispositions diverses en matière de santé soit quasiment vide, alors que, depuis plus d'un an, nous avons la possibilité de travailler à partir de propositions déposées par les parlementaires.

J'espère donc, et je le dis à l'intention des membres de la majorité et de la ministre, que nous pourrons aboutir avant les vacances parlementaires et que nous pourrons disposer de la ministre pour mener à bien ces travaux au sein de la commission. Pour ces différentes raisons, nous nous abstiendrons sur ce texte.

Monsieur le président, madame et messieurs les ministres, je ne reviendrai plus sur les décisions de la Dento-Mut, puisque j'ai profité du débat animé entre les uns et les autres pour donner mon avis.

Ce projet de loi comporte plusieurs dispositions intéressantes en termes de simplification de procédures ou d'usages antibiotiques pour les animaux, même si, puisque cette partie vous concerne, monsieur le ministre, il faudra essayer de prendre en compte la situation des vétérinaires d'autoroute.

Un point positif porte sur l'entrée en vigueur plus rapide de l'autorisation en matière de remboursement pour les médicaments. Il serait bon de se donner des deadlines et de s'obliger, comme État, à les respecter. Pour le secteur pharmaceutique, cela reste un point faible.

Concernant la pédiatrie, on peut relever un élément intéressant. Pour les affections pédiatriques, on sait que 80 % des médicaments font l'objet d'une utilisation off-label; sur ce point, je rappelle qu'une étude du KCE a été réalisée. Je ne peux que plaider auprès du gouvernement pour qu'il travaille sur les recommandations du KCE sur les médicaments off-label. Tant pour les enfants que pour les prestataires de soins, c'est un dossier sur lequel il me semble important d'enfin avancer.

Je ne vais pas reparler de toute une série d'aspects déjà évoqués en commission. J'ai essentiellement deux points à mettre en évidence et qui posent problème, selon moi. Premièrement, je trouve vraiment dommage que la ministre de la Santé – et encore plus dans des projets de loi tel que celui-ci qui sont des projets melting-pot avec des dispositions diverses –, touche de nouveau au financement des hôpitaux. En la matière, une série de décisions ont été prises depuis le début de la législature alors même que le chantier sur la réforme du financement des hôpitaux est en cours et n'est pas abouti.

Successivement, tous les deux ou trois mois, nous avons un impact négatif avec des effets négatifs importants sur les budgets des hôpitaux. In fine, une opacité demeure sur le fait de savoir où l'on va et quel sera réellement le mécanisme de financement des hôpitaux de demain.

Je ne peux que plaider pour qu'on ne continue pas avec cette approche. Il faut aller voir la réalité des hôpitaux. Je rappelle que l'étude MAHA montre que 40 % des hôpitaux sont dans le rouge, malgré une gestion professionnelle en termes budgétaires. Et je ne prendrai qu'un exemple, que je ne peux m'empêcher de citer parce qu'il est assez caricatural: la ministre a pris la décision, dans un projet de loi, de supprimer purement et simplement les articles de loi qui concernent le financement d'une compétence qui touche singulièrement l'hôpital – c'est le cas ici pour l'hémodialyse, la dialyse péritonéale et la dialyse extra-hospitalière – sans prévoir d'autres dispositions à la place. C'est juste le vide. On ne sait pas, on discute, on concerte; c'est exact, les associations sont concertées et une réunion a d'ailleurs encore eu lieu ce matin. La logique voudrait évidemment que dans le même texte, même s'il s'agit encore de dispositions diverses, on supprime les articles sur le financement et on fasse apparaître, de façon transparente, les nouvelles décisions et la manière de financer. C'est à la fois de la bonne gestion et de la gestion responsable et transparente. Cela permet aussi aux hôpitaux et aux prestataires de soins de voir clair en disposant de l'ensemble des données.

Le deuxième enjeu qui me pose problème – vous vous en douterez, chers collègues de la commission de la Santé –, c'est tout ce qui concerne l'approche en matière de lutte contre le tabac. Dans ce projet de loi portant des dispositions diverses, on transpose la directive européenne mais on ne fait, dans le fond, que traduire la position obligatoire de la directive européenne en laissant de côté tout ce que cette directive permet aux États membres et leur donne comme liberté, pour le renvoyer à plus tard, voire à jamais. C'est la loi du moindre effort. La position est ultra minimaliste.

À cet égard, chers collègues, je voudrais vous informer d'une série de nouvelles décisions qui viennent de tomber au nouveau judiciaire et juridique.

Par exemple, rien que pour le mois de mai 2016, le 4 mai 2016, la Cour européenne de Justice a confirmé l'avis émis par l'avocat général en date du 23 décembre 2015 et a jugé que la directive tabac européenne était conforme à la législation européenne et que les pays membres pouvaient introduire les paquets neutres à l'image du Royaume-Uni, de la France et de l'Irlande.

Le 19 mai 2016, la Haute Cour de Justice britannique a rendu un verdict très détaillé, de plus de 300 pages, dans lequel elle rejette toute l'argumentation de l'industrie du tabac relative au paquet neutre. Les arguments de l'industrie du tabac qui portaient sur un manque d'efficacité de cette mesure, sur le respect de la propriété intellectuelle ou encore sur l'augmentation du commerce illégal, tous ces arguments de l'industrie du tabac sont rejetés purement et simplement par la Haute Cour de Justice britannique. Ce sont des arguments qui doivent vous parler, chers collègues, puisque ces arguments, vous les utilisiez en relayant évidemment le lobby du tabac.

La Haute Cour de Justice britannique a également estimé que les milliards réclamés par l'industrie du tabac à titre de dommages et intérêts étaient hors propos, considérant que le tabagisme est la cause de véritables épidémies de diverses maladies. Rien qu'en Belgique, nous enregistrons 20 000 décès prématurés chaque année, sans compter le grand nombre de patients atteints d'un cancer – rappelons que le tabac est la première cause de cancer – et toute une série de maladies pulmonaires ou cardiovasculaires.

Tous ces avis rejoignent à la fois l'avis de la Cour constitutionnelle australienne, du Conseil constitutionnel français du 21 janvier 2016 ou encore, je le disais à l'instant, de la Cour européenne de Justice et de la Haute Cour de Justice britannique. Tout ceci pour vous dire que nous aurions pu, non, nous aurions dû profiter de la transposition de la directive européenne pour également faire des avancées importantes en matière de lutte contre le tabac.

Je plaide et je continuerai à plaider pour qu'on puisse avancer sur la mise en place du paquet neutre et sur la suppression de la dérogation qu'il reste en matière d'interdiction de la publicité. Monsieur le ministre, cela fait plus de dix ans que la Belgique a ratifié la convention de l'Organisation mondiale de la Santé pour interdire complètement la publicité pour le tabac et on ne la respecte toujours pas. Nous sommes de très mauvais élèves en la matière.

Je plaide également pour qu'on avance dans la protection des mineurs en matière de tabagisme passif dans les aires de jeu et dans les véhicules.

Enfin, je continue à plaider pour que l'e-cigarette soit plutôt vendue en pharmacie, car cela permettrait d'en faire une véritable aide à l'arrêt du tabac, plutôt que d'en faire ce qu'elle est aujourd'hui, à savoir une nouvelle porte d'entrée dans le monde du tabac pour les jeunes.

J'ai redéposé les amendements qui concernent les différents aspects du tabac que je viens d'évoquer. Je peux vous assurer que je ne cesserai jamais de déployer un maximum d'énergie en matière de lutte contre le tabac, en lien avec les experts tabacologues et la Fondation contre le Cancer. J'ai vu trop de patients souffrir et mourir des effets du tabac que pour lâcher prise et pour ne pas mener le combat.

Monsieur le président, je vous prie d'excuser Mme la ministre de la Santé. J'ai eu l'occasion de réagir directement au sujet des soins bucco-dentaires.

En ce qui concerne le point important évoqué par plusieurs intervenants, je vous confirme la présence de Mme la ministre de la Santé, très prochainement, en commission dans le but de discuter de l'ensemble des mesures dans le contexte de la lutte contre le tabagisme.

Indépendamment de la transcription a minima qui a été actée en commission et qui vous est proposée aujourd'hui, il est bien évident que l'ensemble du débat sur la lutte contre le tabagisme aura lieu. Mme De Block m'indique qu'elle sollicitera très prochainement la mise à l'ordre du jour d'un débat en commission de la Santé publique.

J'en viens aux autres éléments d'information plus techniques, concernant notamment la disposition, l'organisation et l'articulation avec le trajet de soins. Eu égard aux dispositions relatives à l'organisation technique de l'agrément des médicaments, les modalités d'accélération de celui-ci, la ministre de la Santé m'indique aussi qu'elle transmettra les informations à la commission.

J'acte, nonobstant un certain nombre de points de divergence, la tonalité positive de certains commentaires, les accélérations que vous avez bien voulu souligner dans les procédures de reconnaissance ainsi que la tonalité globalement positive de certaines intentions d'abstention qui nous ont été annoncées.