The Devil in the Details

In its 2018 report, the Broadbent Institute ran down the history of efforts to institute pharmacare in Canada. The idea first appeared on the national scene in 1945, as part of discussions over national Medicare policy ideas. It didn’t make the cut as part of the universal single-payer medical insurance program that emerged in the 1960s, but the idea is a popular one and the issue has been kept alive by stubborn public support. As the report mentions, in 1997, Liberal prime minister Jean Chrétien’s government promised to “develop a national plan, timetable and a fiscal framework for providing Canadians with better access to medically necessary drugs.” That didn’t happen. Moreover, it sounds quite a bit like the promise Prime Minister Justin Trudeau and NDP leader Jagmeet Singh have just made.

The supply and confidence agreement pledges “continuing progress towards a universal national pharmacare program by passing a Canada Pharmacare Act by the end of 2023 and then tasking the National Drug Agency to develop a national formulary of essential medicines and bulk-purchasing plan by the end of the agreement.” But what does all this mean?

The National Drug Agency and the national formulary it develops are key components of a pharmacare plan, essential to both determining which medications will be covered and keeping drug prices in check. A bulk-purchasing plan is also essential — it is a means of coordinating procurement and further keeping prices in check. Together, these details point to a concrete promise that gives us a sense of what the program might look like as we await further information.

However, the risk of a slow, uneven, piecemeal program is high — the NDP has admitted as much. There is also the risk that the process forges ahead but founders on a Conservative Party election win. If the Conservatives form the government before the program is in place, its implementation is highly doubtful.

The one thing about the program we know for sure is that it will take time. The Canada Pharmacare Act, promised by the end of 2023, is simply the beginning. As Chris Parsons, provincial coordinator for the Nova Scotia Health Coalition puts it, “You don’t create this program with an act.” He says the act, while essential, is nothing without the negotiations and wrangling with federal departments, provincial and territorial governments, drug companies, pharmacists, insurance companies, labor unions, and others that will make pharmacare a reality.

The act will, however, serve as a framework outlining the standards, responsibilities, and principles of the program. It may, in fact, resemble the Canada Health Act, the framework for the country’s Medicare program. The Canada Health Act outlines the objectives of health insurance and the five principles of the program: comprehensiveness, universality, portability, public administration, and accessibility. It also places limits and conditions on funding, including a prohibition on charging user fees.

The Roadmap and the Battle Ahead

We may not know what the Canada Pharmacare Act will look like, but there is a roadmap we might consult to get an idea — and some goals. In 2019, the “Hoskins report,” A Prescription for Canada: Achieving Pharmacare for All, chaired by former Ontario health minister Dr Eric Hoskins, recommended “a universal, single-payer, public system of prescription drug coverage in Canada.” It recommended that the five principles of Medicare be replicated for pharmacare. This idea ought to serve as a guide for much of the federal program, and we ought not to compromise on its most comprehensive recommendations.

Beyond the framework legislation, the development of the program itself requires the creation of a detailed federal scheme and support apparatus that will be administered and paid for solely by the national government. Another acceptable solution would be a series of provincial and territorial programs geared to national standards and cost-shared between the national and subnational governments.

The Broadbent Institute report made the case for a national program, but the most likely approach will be provincial and territorial arrangements similar to the current public health care system arrangement. The challenge with the provincial and territorial approach is that the federal government will need to negotiate multiple deals, some of which will require intransigent Conservative-led provinces to jump on board.

The theory of federalism that guides much of Canadian politics suggests that public pressure will induce provinces and territories to join, especially if their residents see other subnational units sign on to a desirable program. That theory could hold, as it did, more or less, in the last year with $10-a-day childcare deals across much of the country (perhaps even in Ontario).

Pharmacare is popular in Canada. In 2019, a poll conducted by the Heart and Stroke Foundation and the Canadian Federation of Nurses Unions found Canadian support for the idea at just under 90 percent. But that doesn’t guarantee that the program will see the light of day. Having a provincial champion of the program in a large province such as Ontario (unlikely), Quebec (very unlikely), or British Columbia (conceivable) would be a big help, but none may wish to stick their necks out any time soon.

While provincial resistance could become a serious barrier to pharmacare, the pharmaceutical and insurance industries will be fighting like hell to resist a comprehensive public prescription program. This industry pushback will make things more difficult still. The industry stands to lose influence and, more to the point, profits. Organizing, public pressure, and direct action both nationally and subnationally will still be necessary to make pharmacare a reality. The NDP will also have to commit to holding the Liberals to account — and their history on this is spotty.

The future of pharmacare in Canada is still to be determined. For decades, the country has talked about it, but this opportunity, while still at distance, seems real. This is a critical juncture — a historical moment, contingent and fleeting. It will require a fight.

Now the hardest work of all begins: capitalizing on the moment and fighting not just for pharmacare but for the program Canadians deserve. That means a universal, single-payer, comprehensive program that covers hundreds of medications without the burden and barrier of co-pays. That means a bulk-purchasing scheme and the close monitoring of prescription trends to control prices and limit abuses of the system by Big Pharma. That means patent reforms to ensure that pharmaceutical giants don’t continue to game the patent system to keep generic drugs off the shelves. The Liberal-NDP agreement offers a chance to push Canada further toward a true, complete public health system. In the past, pharmacare has been tabled only to be scrapped. This time, we mustn’t let the chance slip away.