Pharmacare Bill
Second Reading--Debate
June 18, 2024
Honourable senators, I rise to speak at second reading of Bill C-64, An Act respecting pharmacare. I am deeply appreciative of your time in light of the hour and of the particular date in our legislative calendar. Mindful that it’s our desire to refer Bill C-64 to committee for further study, I rise to share with you a personal perspective with the intent that this story of my region will provide some insights and some questions for the committee’s study.
You are aware that I served as the Yukon premier from 2000 until 2002. At that time, it was also customary for the premier to serve as the finance minister. It was also a time of intense negotiations and discussions about health care costs, especially in the Yukon case, because the Martin government had reduced the Canada Health and Social Transfers quite significantly. In the Yukon’s case, that was especially significant for a small territorial budget of less than $1 billion.
My term also included Team Canada Trade Missions trips with then-Prime Minister Chrétien. For colleagues who may have forgotten, Team Canada trips were trade missions organized by the Prime Minister that included all provincial and territorial premiers, as well as business and community leaders. Relationships are built when leaders break bread together and share a common purpose of promoting our great country.
There are two specific actions that could be attributed to the premiers and the Prime Minister travelling together that relate to our discussions today. One was that Prime Minister Chrétien tasked Roy Romanow with the Commission on the Future of Health Care in Canada. One of the key recommendations from the Romanow commission was to introduce a limited pharmacare program to cover high-price drug treatments. Another recommendation was that:
Canada Health Infoway should continue to take the lead on this initiative and be responsible for developing a pan‑Canadian electronic health record framework built upon provincial systems, including ensuring the interoperability of current electronic health information systems and addressing issues such as security standards and harmonizing privacy policies.
The premise underlying Canada Health Infoway was the concern expressed by Prime Minister Chrétien that when physicians were treating a former colleague of his in a hospital in British Columbia, they should have been able to access all of his health information via his provincial health care record.
Honourable senators, I continued to serve until 2006 as a member of the Yukon legislature following the defeat of our government. My retirement as a legislator began a career in the public service in health care administration. You might say I’d been well inoculated during discussions surrounding health care. I was often heard to say, “Wow, I wish I’d known then what I know now.”
My tasks as the manager of health care registration included the administration of what had been discussed on those Team Canada missions some years previously: the challenges of interprovincial reciprocal billing; ensuring Canadians maintain their health care registration when moving between provinces; and how Canadians longed for a health care card that would provide health care providers with as much information as possible, no matter where they received treatment in the country, and still protect their privacy.
My responsibilities also included claims — the payment of physicians who operated on a fee-for-service basis — which gives me a particular view on the current debate regarding the capital gains tax and how the fee-for-service structure with physicians has shaped and continues to shape medical care in this country. Over the summer months, I look forward to reading former health minister Jane Philpott’s recently released book Health for All: A Doctor’s Prescription for a Healthier Canada.
My duties included managing medical travel. Honourable senators will be aware that Canadians from remote communities are flown to major centres to receive health care treatment. For those who are referred medically out of the Yukon, travel is paid for by the Yukon government, whether by medevac plane or commercial aircraft.
The Romanow commission also called for a rural and remote access fund to provide timely access to care in rural and remote areas. During my term as premier, at my first Western Premiers’ Conference, the first conference hosted by then-Manitoba premier Gary Doer, he stated that Canada must recognize they are the fourteenth province at the table. Canada is responsible for health care costs for Indigenous peoples; the Canadian Armed Forces; and, in some instances, federal government employees, such as the RCMP.
In the context of medical travel at that Western Premiers’ Conference, Premier Doer was talking about the high costs of bringing patients from the North to the South for dialysis. What medical travel meant for me as the manager of registration claims for the Yukon government was that I would regularly be dealing with Canada when the Yukon paid for travel — for example, a one-way $15,000 flight for a status First Nations person — that Non-Insured Health Benefits should have been paying for.
So when medical travel forms a good portion of the health care budget, every $15,000 bill that you can submit to another government — in this case, the Yukon government submitting it to the Government of Canada — is critical.
I am sharing this example and story to highlight for senators the responsibilities that Canada has in health care delivery in our country, which must be included in the discussions of any program that is to be made available to all Canadians. Canada’s responsibility includes being more than the legislative lead and a primary funder in this discussion.
Most importantly, my manager responsibilities also included working closely with the manager of the extended health care benefits and Pharmacare program for the Yukon health care system. That program provided then, as it does today, pharmaceutical drugs for persons over the age of 65 and persons married to someone over the age of 65. Submissions are made to a drug plan — if you have one — and the government pays the balance. If a senior citizen does not have a drug plan, they do not go without physician-prescribed drugs in the Yukon. They are paid for by Yukon health care. If you are a First Nations citizen, Non-Insured Health Benefits pay for those drugs.
Honourable senators, I have to share a story with you, again from my experience working in the health care department. At that time, Avastin, a drug for bladder cancer, was being used off‑label to treat macular degeneration. We had an individual come in who could access Avastin through non-insured health benefits, but not the Yukon extended health benefits because our formularies were different.
Yukon ultimately matched the non-insured health benefits formulary. But the formulary, administration and slow approval of drugs for First Nations children are some of the reasons why tragedy occurred in Manitoba, and why we have the program Jordan’s Principle.
Also, the stated purpose of Bill C-64 is “. . . to support the development of a national formulary . . .” This will be challenging. We have all borne witness to the stories in the news, most recently one from British Columbia concerning a specific drug to treat multiple sclerosis. It was approved in Alberta, but the client in British Columbia was unable to access it due to the cost. I don’t know of a provincial or territorial legislator or official who has not dealt with questions from constituents regarding access to drugs.
A framework for drugs for rare diseases poses extraordinary costs for smaller jurisdictions, and these concerns must be recognized. Also, the Western provinces have been discussing and/or negotiating a collaborative purchase of drugs for some years, as the larger provinces have done individually. Acting together, as one country, we will be better served in our discussions with pharmaceutical companies.
A final note about the extended benefits program in the Yukon — if you have a chronic disease or a disability, you are most likely able to receive help with your costs. For example, if your health care practitioner recommends prescription drugs or medical surgical supplies to treat diabetes, support is provided through the Chronic Disease and Disability Benefits Program. The list of chronic diseases is comprehensive, and so is the assistance.
Bill C-64 is a legislative framework to plan for national programs similar to what the Yukon already has in place. Senator Pate has described Bill C-64 as:
. . . a plan to work with all provinces and territories willing to provide universal single-payer coverage of necessary medicines, starting with a number of contraceptive —
— medications, which are not currently covered in the Yukon —
— and diabetes medications. . . .
— which are covered.
You’ve heard me state on many occasions that federalism is challenging work. I believe we have all stated that the devil is in the details. I appreciate that the details and actual administration of implementing legislation are, in the eyes of some, not necessarily the purview or responsibility of this august chamber.
However, just as we must be assured that all legislation adheres with the Charter and our goals of reconciliation, I’m of the view that in providing our sober second thought to legislation, we also have a responsibility to ensure that the legislation can meet the stated goals. In this situation, a plan for pharmacare in Canada as intended by Bill C-64 can be achieved. The importance of this bill has been eloquently stated by others, including the medical professionals among us. I agree with them.
The committee that will study this bill should consider how a plan that is to be developed between Canada and all the provinces and territories will deliver a pharmacare program for Canadians.
I have shared with you today that this is not a new debate or discussion. I have used only one of the many studies and reports that have recommended a national pharmacare program. I’ve referenced the Romanow Commission.
I have also shared with you my experience in the Yukon, both front line and political. I have shared this purposely as we refer this bill to committee. I will borrow a quote from the June 13, 2024, report of the Standing Senate Committee on National Finance, which stated:
Finally, your committee notes that Bill C-69 contains many measures whose successful implementation requires close collaboration with provincial and territorial governments . . . .
Bill C-64 will require close collaboration with provinces and territories. In relaying this example, I hope I have convinced my colleagues to pay close attention in their study of this bill to the experiences of the territories and provinces, and to recognize Canada’s responsibilities.
Ultimately, I hope the committee will conclude — perhaps with observations, after reviewing all the evidence from the many reports, commissions and speeches recommending a national pharmacare program — that bill will be enacted and the program will come to be.
In the languages of the Yukon First Nations, shä̀w níthän, mahsi’cho, gùnáłchîsh. Thank you.
Honourable senators, I rise today as the opposition critic to speak at second reading to Bill C-64, An Act respecting pharmacare. I want to thank Senator Pate, the sponsor of Bill C-64, and Senators Osler, Moodie, Simons, Bernard and Duncan for their insights on this important piece of legislation.
I will now look at the bill.
Colleagues, Bill C-64 seems to propose two distinct policies. On the one hand, Bill C-64 proposes national universal pharmacare and sets out the essential principles that the Minister of Health is to consider when working toward the implementation of this policy.
On the other hand, the bill codifies a structure and processes which oblige the Minister of Health to make payments to those provinces with which the federal government has made bilateral agreements in order to increase any existing public pharmacare coverage for specific prescription drugs and related products intended for contraception or the treatment of diabetes. It’s a tale of two policies.
Colleagues, I will consider some of the issues that confront us in Bill C-64, both in the proposal for national universal pharmacare and the incremental plan for drugs and products intended solely for contraception or the treatment of diabetes. I will also consider three overarching, structural concerns which I believe should be examined at committee.
The national universal pharmacare framework proposed in Bill C-64 seems to express principles in keeping with the policy envisioned by A Prescription for Canada: Achieving Pharmacare for All, the final report of the Advisory Council on the Implementation of National Pharmacare.
The advisory council was launched in June 2018 and chaired by Dr. Eric Hoskins. Its final report, published in June 2019 and often referred to as “the Hoskins Report,” proposed “. . . the government enact national pharmacare through new legislation embodying the five fundamental principles in the Canada Health Act. . . .”
In keeping with the Hoskins Report, commitments have been made for foundational elements, including the Canadian Drug Agency, the National Formularly and the National Strategy for Drugs for Rare Diseases.
In 2021, the federal government invested $35 million with Prince Edward Island for the Improving Affordable Access to Prescription Drugs Program as a kind of pilot study for fill‑in‑the-gap coverage.
In 2022, a multidisciplinary national panel convened by the Canadian Agency for Drugs and Technologies in Health, or CADTH, at the request of Health Canada, recommended a framework for developing a national formulary and a sample list of drugs.
In March 2023, the National Strategy for Drugs for Rare Diseases was launched with an investment of up to $1.5 billion over three years to increase access to and the affordability of drugs for rare diseases.
In December 2023, the Canadian Drug Agency was created with an investment of $89.5 million over five years starting in 2024-25.
Bill C-64, the government asserts, is the next step toward national universal pharmacare. However, there are considerable weaknesses to this particular proposal for national universal pharmacare. As my colleagues often hear me emphasize around proposed legislation, there may be serious unintended consequences. Let’s explore that.
First, the national universal pharmacare policy envisioned by Bill C-64 infringes on provincial jurisdiction and complicates or interferes with programs the provinces and territories already have in place.
As we understand, in Canada, provincial and territorial governments are responsible for the management, organization and delivery of health care services for their residents. Quebec — which requires that all residents who do not have private drug insurance must enrol in the province’s premium-based public plan — is the only province to have achieved universal drug coverage. Given this, Quebec’s government objects to Bill C-64.
In February, the office of Christian Dubé, Quebec’s Minister of Health and Social Services, told The Canadian Press:
The Quebec government has repeatedly pointed out that health is an exclusive Quebec jurisdiction. If the Government of Canada goes ahead with this drug insurance project, the Government of Quebec will demand the right to opt out with full compensation . . . .
Quebec is not alone in this objection. The Government of Alberta has expressed similar sentiments.
All provincial and territorial governments offer prescription drug coverage programs, albeit of different types, for their residents. Let me provide just an overview of some of the public programs across Canada which cover prescription drugs, medical devices and supplies. Some are based on income, some are based on age, and some add specific disease entities, which require expensive medications.
Alberta has a plan that covers adults from low-income households with high ongoing prescription needs or who are pregnant; children in low-income households; residents who are 65 years of age and older; and the Non-Group Coverage program — administered by Alberta Blue Cross — which charges monthly premiums and is available to all Albertans.
British Columbia has a plan that covers residents receiving income assistance; residents of licensed residential care facilities; and Fair PharmaCare, which helps B.C. families pay for prescription drugs. Fair PharmaCare is based on income — the less a family earns, the more assistance they receive.
Manitoba’s Pharmacare program provides income-tested benefits for residents whose prescription costs are high.
New Brunswick has a plan that covers residents over 65 years of age; those in a nursing home; children in the province’s care; social development clients; and a plan that provides income‑tested benefits for residents who do not have private insurance.
Newfoundland and Labrador has a plan that covers low‑income individuals and families; and residents over 65 years of age who receive Old Age Security and the Guaranteed Income Supplement.
The Northwest Territories has a plan that covers eligible residents 60 years of age and older and residents diagnosed with specific diseases, and a plan that covers Indigenous Métis residents.
Nova Scotia has a plan that covers all residents without any other drug plan, or who have excessive drug costs.
Nunavut has a plan that covers seniors and residents diagnosed with certain illnesses, and residents receiving income support.
Ontario has plans that cover residents over 65 years of age; residents receiving social assistance; residents in long-term or special homes; residents receiving home care; and residents with high prescription drug costs — based on income — who do not have private coverage or another provincial plan. And Ontario has a plan that covers more than 5,000 drugs at no cost for anyone 24 years of age or younger who is not covered by a private plan.
Prince Edward Island has a plan that covers low-income families; residents 65 years of age and older; residents under age 65 who do not have drug insurance; and residents who need assistance to pay for drugs and supplies for a range of specific medical conditions. Further, in 2021, P.E.I. entered into a partnership with the federal government for a pilot program that reduced co-pays for eligible medications to $5 — including medications for cardiovascular disease, diabetes and mental health — for residents covered under certain programs.
In Quebec, the Public Prescription Drug Insurance Plan covers all residents who are not covered by a private plan.
Saskatchewan has a plan that covers all residents except those on federal programs.
The Yukon has a plan that covers residents over age 65 and children from low-income families, and that provides benefits for Yukon residents who have a chronic disease or a serious functional disability. Our colleague Senator Duncan has very well described their plan in much more detail.
Depending on program design, national universal pharmacare could simplify the complex array of programs in place across Canada. But there is institutional knowledge regarding program delivery in each of our provinces and territories, and there are tailored programs in place to meet the needs of our communities. Quebec, for instance, has almost 30 years of experience with its program.
Furthermore, most Canadians do have existing drug coverage. Statistics vary depending on the source you reference. As the Advisory Council on the Implementation of National Pharmacare notes in the Hoskins report:
Our research turned up different estimates of how many Canadians are uninsured or underinsured: some studies put the number of uninsured at 5 per cent of Canadians . . . . Other surveys tell us closer to 20 per cent of Canadians . . . are either uninsured or underinsured . . . .
Those who don’t have existing drug coverage may be eligible for a program in which they are not enrolled. In a 2022 pan‑Canadian analysis of prescription drug insurance coverage, The Conference Board of Canada estimates that more than 97% of Canadians are eligible for some form of prescription drug coverage. That leaves a 2.8% gap of Canadians who are not eligible for coverage. In addition, The Conference Board of Canada notes that approximately 10% of Canadians are not enrolled in a public or private plan for which they are eligible.
Second, the national universal pharmacare policy contemplated by Bill C-64 may have a negative impact on pharmacists’ practice. In testimony to the Standing Committee on Health in the other place, pharmacists expressed concerns about a national universal pharmacare plan. Joelle Walker from the Canadian Pharmacists Association highlighted the administrative burden involved in switching patients from one plan to another:
. . . the potential for significant disruption can’t be overstated. . . . changing drug plans can be very disruptive for plan members and for pharmacists.
The reality is that public drug plans across Canada are far less comprehensive than private plans, which means that if the legislation shifts patients from their private plans to a public plan, pharmacists and physicians will likely have to spend a considerable amount of time switching patients to new therapies, especially if their drug is no longer covered under a public plan; filling out paperwork to get special exemptions; and communicating these changes to patients.
Benoit Morin, President of the Association québécoise des pharmaciens propriétaires, told the Standing Committee on Health that under a public single-payer principle, dispensing fees would be a single amount negotiated for covered drugs. He explained that this would have a significant impact on Quebec proprietor pharmacists because dispensing fees are higher for drugs covered by private plans, including the private component of Quebec’s Public Prescription Drug Insurance Plan.
Here’s the importance of that point. He said:
The current funding of Quebec pharmacies relies mainly on professional fees associated with the dispensing and monitoring of prescription drugs. Variations in those fees can influence pharmacies’ ability to provide services to patients. . . .
It is precisely the flexibility of the present mixed public‑private model that enables Quebec pharmacies to develop, operate in all regions and provide a host of services to patients. . . . Without that flexibility, the financial health of the pharmacy network would be undermined, and the impact would be even greater in remote regions.
Mr. Morin also noted:
Some 371 pharmacies shut down when a universal plan was introduced in New Zealand.
We’re afraid that, if there’s no mixed system in Quebec, pharmacies will find it hard to be profitable, which will result in closures and force them to set up in major centres rather than rural areas.
The federal government has a pattern of not consulting pharmacists on policies which will directly impact both them and the Canadians whom they serve. In a press release issued after Bill C-64 was tabled in the other place, the association lamented that there were no pharmacists on the 2018 Hoskins Advisory Council on the Implementation of National Pharmacare.
The care that Canadians receive at pharmacies is irreplaceable. According to research conducted for the Canadian Pharmacists Association by Abacus Data in September 2023, 37% of Canadians visit a pharmacy at least once a month, and 23% speak with a pharmacist at least once a month.
Pharmacists’ scope of practice varies across the country, but, depending on jurisdiction, pharmacists can prescribe medications, make therapeutic substitutions and change drug dosages, formulations, regimens, et cetera. In all provinces and in the Yukon, pharmacists can inject drugs and vaccines. In Alberta and Quebec, pharmacists can even order and interpret lab tests.
Pharmacists’ scope of practice continues to grow. As more and more Canadians report not having a family doctor, a majority of those surveyed by Abacus agreed that expanding the range of services offered at pharmacies — including walk-in clinics for common ailments, vaccinations, testing and lab services, chronic disease management and prescribing contraception — would enhance access to and quality of health care.
Such ambitions could be realized in a context in which local pharmacies can thrive. In an op-ed in The Hill Times, Sandra Hanna, a community pharmacist and pharmacy owner in Guelph and the Chief Executive Officer of the Neighbourhood Pharmacy Association of Canada, notes that:
Over the past few years, pharmacies and their teams have played an increasingly important role as primary health-care providers, particularly in rural and remote regions. . . .
She warns, however, that a single-payer pharmacare program would cost the pharmacy sector $1 billion annually, which is equal to cutting approximately 20 million pharmacist hours.
Currently, Canadians have excellent access to pharmacies. According to Organisation for Economic Co-operation and Development, or OECD, data, in 2021, Canada had 30 pharmacies per 100,000 population, more pharmacies than the OECD average. Can we, in our current health care ecosystem, afford to jeopardize the success of our pharmacies and pharmacists? This is a potential unintended consequence that we should examine at committee.
Third, the national universal pharmacare policy contemplated by Bill C-64 could erode access to drugs and exacerbate drug shortages. The Standing Committee on Health, or HESA, heard from several stakeholders who were concerned that, depending on the ultimate contents of a national formulary, the national universal pharmacare plan proposed in Bill C-64 may worsen drug availability.
Angelique Berg, the President and Chief Executive Officer at the Canadian Association for Pharmacy Distribution Management, told the committee:
. . . Because they run so efficiently, reduced funding means that distributors have few options left but to reduce services. Some examples are that they could stop carrying money‑losing products . . . reduce safety stock . . . or reduce delivery frequency to high-cost regions . . . .
. . . When the government awards a contract to a single manufacturer, that firm effectively becomes a monopoly, so competitors have little incentive to stay in the market. Concentrated marked power increases the risk of limited supply, and therein lies our concern.
The Canadian Pharmacists Association shared Ms. Berg’s concern about drug shortages. Ms. Walker said:
One thing that we’ve noted is that the number of available medications in each drug class can decrease significantly, depending on how many companies are in the market, and we are most vulnerable to drug shortages if only one or two manufacturers are producing a particular drug.
Let’s say that there’s a national disaster in one country that’s producing some of the API, and the one company there can’t produce that drug, and the other companies aren’t able to readily increase their production. . . . there’s a really complicated ecosystem that this pharmacare approach needs to also recognize.
The Montreal Economic Institute has also flagged concerns that if national universal pharmacare was implemented in Canada, drug distribution could be interrupted. They write:
. . . if certain drugs are no longer covered by an insurance plan, it is very likely that pharmaceutical companies will stop distributing them in Canada. The variety of medications in circulation in this country is therefore at risk of shrinking, preventing previously covered patients from having access to these drugs, even if they were disposed to pay for them out of their own pocket.
Drug shortages are not uncommon in Canada. In December 2018, I asked the Leader of the Government in the Senate about a Canada-wide shortage of the antidepressant Wellbutrin. In February 2020, I asked about a shortage of tamoxifen, a drug used as part of hormone therapy to treat breast cancer. In June 2020, I asked about shortages of thyroid drugs, inhalers, blood pressure medication and glaucoma eye drops. In November 2022, I asked about a shortage of pediatric amoxicillin.
Pharmacists already navigate drug shortages in Canada. Committee hearings should carefully consider the unintended consequences of fewer available medications in Canada.
