Honourable senators, in the last episode of Senator Osler’s speech on Bill C-64, I was talking about a short background on pharmacare, my concerns and then my hopes for pharmacare.

Bill C-64 has been called the most significant piece of health policy legislation since the 1984 Canada Health Act, which enshrined in law the core principles of Canada’s public health care system: that it be publicly administered, comprehensive, universal, portable and accessible to all.

Canada remains the only country in the world to offer universal health care without pharmacare. Bill C-64 aims to deliver that missing piece, universal prescription drug coverage, and proposes the foundational principles for the first phase of national universal pharmacare in Canada.

It describes the Government of Canada’s intent to work with the provinces and territories to provide universal, single-payer coverage for certain diabetes medications and contraception.

Minister Holland has acknowledged that the government is approaching pharmacare in stages and that there is “. . . not universal consensus on where a national pharmacare program will go.”

Despite these intentions, Bill C-64 has raised concerns. Dr. Steven Morgan, Canada’s leading expert on pharmacare systems, wrote in the August 12, 2024, edition of the Canadian Medical Association Journal:

The legislation promises to provide immediate coverage of contraceptives and diabetes medications, but it does not ensure universal, public coverage of those medications. As written, Bill C-64 will merely fill the gaps in Canada’s existing patchwork of more than 100 public drug plans and thousands of private ones, cementing into law a model of national pharmacare that was rejected in 2019 by the government’s Advisory Council on the Implementation of National Pharmacare, as well as by 4 previous national inquiries. A fill-the-gaps pharmacare system will not give Canada the institutional capacity needed to fairly and efficiently provide universal access to appropriately prescribed, affordably priced, and equitably financed medicines in a global context of powerful players and growing challenges regarding the reasonableness and transparency of pharmaceutical pricing.

He concludes his article by saying:

Unamended, Bill C-64 will create a fill-the-gaps system involving unnecessary complexity, fragmented purchasing power, inequitable financing, and potentially conflicted coverage decision-making.

The Standing Senate Committee on Social Affairs, Science and Technology, also known as SOCI, began studying Bill C-64 on September 18, 2024, and heard from Minister Holland. In response to a question from Senator Moodie on why the Senate should not amend the bill, Minister Holland answered:

I’m deeply respectful of your chamber, and you have such an important role to play in reviewing legislation and suggesting amendments. This is a bit different in that it was balanced on a pinhead. This is, by far — and I’ve been involved in a lot of complex things — the most difficult bit of business I’ve ever been in. Every syllable and word in this bill was debated and argued over. It is the result of really important collaboration. It was not one political party but two, with two very different views, finding a way to find common ground.

I freely acknowledge that it’s imperfect, but, in this instance, we have to be very careful of not allowing perfection to be the enemy of progress. We don’t have a lot of time. The reality is that opponents will criticize this as just being fantasy, so if we spend a long time wordsmithing and trying to make the legislation perfect, then the criticism that it’s not real starts to feel real for people because they don’t get drugs and an improvement in their life.

The Merriam-Webster dictionary defines “wordsmith” as someone “who works with words.” Colleagues, some of the words and terms used in Bill C-64 lack definition, which has raised concerns about ambiguity from numerous stakeholders, including, but not limited to, people living with diabetes, pharmacare advocates, academics, insurers, business groups and employers. For example, several terms like “single-payer” and “first-dollar” appear throughout the bill yet are undefined.

Canadian Doctors for Medicare is a national, evidence-based, non-partisan member organization dedicated to strengthening and preserving Canada’s publicly funded health care system. In their brief submitted to Social Affairs, they outlined their concerns.

First, “Bill C-64 does not explicitly commit to the universal, publicly funded, single-payer pharmacare program recommended in the . . . .” Hoskins report.

Second, there is a lack of comprehensiveness in that:

Bill C-64 does not commit the federal government to expanding coverage beyond products for diabetes and contraception. Rather, it only “aims” to continue working toward implementation of a national formulary and national universal pharmacare . . .

Third, the bill does not define the term “universal,” though they presume the intent is to “. . . mimic the criterion in the Canada Health Act . . . ”

Fourth, they have concerns regarding public funding and administration:

Bill C-64 does not explicitly commit to an expanded pharmacare program that is fully publicly funded first-dollar coverage and universal for all essential medicines . . .

Fifth, there is a lack of accountability in that:

Bill C-64 only commits the minister to “considering” the Canada Health Act, not to abiding by the five principles enshrined in the Act . . .

Finally, there is potential for conflicts of interest:

Bill C-64 does not prohibit people with financial conflicts of interest from being appointed to the Committee of Experts that will make recommendations respecting options for the operation and financing of pharmacare.

Despite their concerns with Bill C-64, Canadian Doctors for Medicare urged the Senate to pass the bill because of a strong desire to finally see a national pharmacare program.

Moving on, let’s discuss concerns regarding the Canadian Drug Agency, or CDA.

On December 18, 2023, the Government of Canada announced that the Canadian Drug Agency would be built from the existing Canadian Agency for Drugs and Technologies in Health in partnership with the provinces and territories.

The government announced an investment of $89.5 million over five years to establish the CDA. The CDA’s work will be to improve the appropriate prescribing and use of medications, to increase pan-Canadian data collection and expand access to drug and treatment data and to reduce drug system duplication and lack of coordination that causes expensive inefficiencies and pressures.

However, Bill C-64 does not codify the Canadian Drug Agency into legislation, nor does the bill define its powers, functions or governance structures, all of which could leave the agency vulnerable to interference, diminish its authority and render it potentially dismissible.

Again, to quote Dr. Steve Morgan:

Bill C-64 refers to the Canadian Drug Agency . . . which the government’s Advisory Council had recommended be set up as an arm’s-length agency that would create and maintain the formulary of medicines to be covered by national pharmacare, including negotiating pricing and supply contracts with manufacturers of covered medicines. The Bill requires the federal Minister of Health to seek advice from the agency on several matters concerning drug coverage, prescribing appropriateness, and “bulk purchasing” (another term not defined). However, Bill C-64 does not establish the CDA by law, nor set out the agency’s powers, functions, and governance structures, which represents a missed opportunity to depoliticize the implementation and management of national pharmacare. Without this, if and when Bill C-64 is enacted by Parliament, the scope of authority and very existence of the CDA could be easily changed or terminated by a government, without reforming the Bill. As recent experience in Canada has shown, even a body established by law — such as the Patented Medicine Prices Review Board — is not immune from interference from government and stakeholders. It is therefore imperative to ensure that the scope of the CDA’s authority is clearly established in law, the procedures for communicating and consulting with governments and stakeholders are defined, and security of tenure is granted to the CDA’s leadership in order to ensure the new agency is both publicly accountable and protected from undue outside interference.

As currently written, Bill C-64 does not enshrine Canada’s Drug Agency into law. Concerns have also been raised about the committee of experts established by Bill C-64.

The bill requires the federal Minister of Health to establish and provide for a committee of experts who will “. . . make recommendations respecting options for the operation and financing of national, universal, single-payer pharmacare.”

At the Social Affairs Committee, in response to a question from Senator Cordy on the committee of experts membership, Minister Holland answered:

On the committee of experts, they’re going to be jointly named, as you’re aware, by two political parties — putting both of those names in. The chair will be equally agreed upon. I am absolutely committed to making sure the committee has no concerns around the idea of conflict of interest. It’s so critical that people see this as a group of experts who are squarely and entirely focused on ensuring we have medicine for folks in the most efficacious way that represents the interests of Canadians.

We’ve had very good and easy conversations on that with the NDP, who, in this instance, would be the ones we would be selecting that committee with. Therefore, I don’t believe there’s going to be a problem in terms of a conflict of interest. It’s not what we’re looking for.

Still, in a submitted brief from the Canadian Labour Congress, they call on the government to:

. . . exercise due diligence in the selection of members for the Committee of Experts ensuring that there is no conflict of interest that can influence or shape their work in making recommendations of public benefit respecting options for the operation and financing of national universal single-payer pharmacare. The Committee of Experts’ work is too important, and the common practice of signing disclosure of conflicts forms is not a sufficient safeguard.

Now, before discussing concerns about how the national pharmacare program will be administered, let me give you a brief background on how another federally funded insurance program has recently rolled out.

As you are aware, the provinces and territories administer and deliver most of Canada’s health care services, commonly known as medicare. Medicare does not include coverage for prescription drugs. Similarly, medicare does not cover dental care apart from any medically or dentally required surgical-dental procedures performed by a dentist in a hospital.

The new Canadian Dental Care Plan is a phased dental insurance program funded by the federal government to provide dentistry services to uninsured Canadians who meet certain criteria. Individual eligibility is assessed by Service Canada, and the dental plan is administered by Sun Life Financial under a $747-million contract it signed with the federal government in December 2023.

With that background in mind, let’s get back to national pharmacare. At committee, Minister Holland was asked directly if national pharmacare would be publicly administered. The minister replied, “I’m ambivalent about that.”

Subsequently, in a letter dated September 27, 2024, the minister clarified his intentions about pharmacare and specified that:

. . . the cost of these medications will be paid for and administered through the public plan, rather than through a mix of public and private payers.

Public administration of national pharmacare would have a cost-saving benefit and would support long-term sustainability of the program.

Colleagues, I know you are aware of the calls to pass Bill C-64 without amendments, just as I know we are aware of our duty as senators to carefully consider the legislation initiated by the House of Commons to prevent any hasty or ill-considered legislation that may come from that chamber, to paraphrase Sir John A. Macdonald.

At the Social Affairs Committee’s clause-by-clause meeting, I proposed an amendment, which was ultimately defeated. The amendment was to add the words “publicly administered” to clause 6(1). I proposed the amendment because Bill C-64 is ambiguous about how the national pharmacare program will be administered. The intent was to codify into legislation the minister’s words in his clarifying letter that national pharmacare will be publicly administered.

Note that in the Canada Health Act, “public administration” is defined as requiring the provincial and territorial health care insurance plans to “. . . be administered . . . on a non-profit basis by a public authority . . .” responsible to the provincial government.

On October 1, 2024, the committee received a letter from professors Matthew Herder, Sheila Wildeman, Constance MacIntosh and Jocelyn Downie, who are members of the Health Justice Institute at the Schulich School of Law at Dalhousie University. The law professors examined what effect, if any, the minister’s letter would have on interpreting Bill C-64. They wrote:

In theory, Minister Holland’s letter could be accepted, when read together with the complete legislative history of Bill C-64, as evidence of Parliament’s intention to ensure that pharmacare was publicly administered. However, one would only get to this point if a province or a party with standing chose to invest the money and time into litigating a contrary interpretation, and the letter was identified and brought forward as evidence. The fundamental point is that amending Bill C-64 to include an explicit commitment that pharmacare must be publicly administered is preferable to leaving the legislation open to interpretation, and certainly preferable to allowing an interpretation to be adopted and advanced which is contrary to the Minister’s intentions, unless and until the matter goes before a court.

Amending the legislation would also represent the Senate playing its rightful role in protecting the interests of Canadians. It would ensure that the position that has been put forward by Minister Holland is realized rather than putting that burden on the backs of individual Canadians.

As currently written, Bill C-64 has no explicit commitment to public administration.

As I conclude my remarks, allow me to share my hopes for the future. My biggest hope is that with passage of Bill C-64, all Canadians, especially the people and populations who have been made most vulnerable, will receive the prescription medications they need without unnecessary barriers or hardships. For example, the National Indigenous Diabetes Association pointed out in their brief that:

Access to a number of diabetes and contraception medications is urgently needed by some of the most vulnerable Indigenous Peoples — particularly Non-Status First Nations and Métis — who currently fall outside the NIHB program.

Finally, I leave you with this excerpt from the 2019 Hoskins report:

. . . at the heart of every decision about pharmacare are people, residents of this great country, who deserve to be treated fairly and to have equal access to the best care we can give.

With that statement, I wholeheartedly agree. Colleagues, thank you for your attention. Meegwetch.

Honourable senators, I rise to provide some concluding thoughts on Bill C-64. I want to thank my colleagues for their comments so far and the sponsor of the bill, Senator Pate, for her hard work and dedication in shepherding this complex legislation through the Senate.

I also would like to acknowledge my colleagues in the Social Affairs Committee for an excellent study of the bill and the many witnesses and Canadians who came to testify or who have shared their thoughts and concerns in other ways.

I will be supporting this bill, and I urge you all to do the same.

This bill has received a significant amount of attention because it begins to address an urgent need and evokes a sense of hope for many Canadians. They envisage a world where they have access to life-saving drugs they need in the same way that they have access to other life-saving necessary medical services, and they’re eager to see this hope become a reality.

I join in their eagerness. After all, Canada is the only OECD country with a universal health care program that does not include universal coverage for prescription drugs. I strongly believe that we ought to aspire to a system that is universal, single-payer and publicly funded, often referred to as the Hoskins model. In this model, the government covers the cost of prescription drugs for all Canadians from the first dollar spent, with the promise of no out-of-pocket costs, no deductibles and no confusion over whether you are covered or not.

Consistent with the values of our public medicare system, this is a system that would provide access to comprehensive evidence-based treatments for every Canadian, no matter who you are, where you live, how much money you make or whether or not you have a job.

With a pharmacare system like this, Canadians would not have to choose between paying their rent, buying their groceries or getting the drugs they need. Parents would not have to forgo meals to ensure that their children have vital drugs. Women would not have to remain in abusive relationships to be able to maintain access to insurance for themselves or for their children.

Does Bill C-64 create such a system? Well, the short answer is “no.” It does not. It is not everything that I or many Canadians want it to be. However, I firmly believe that it is a critical first step. Let me explain why.

Universal pharmacare is past due and is vitally necessary. Therefore, any step toward providing a pharmacare program is an important step. The status quo leaves too many Canadians behind, forcing them to make difficult decisions that put their health and their lives at risk. Today, millions of Canadians either have inadequate prescription drug coverage or no coverage at all. For people with chronic conditions like diabetes, the cost of insulin and other life-sustaining treatment can lead to devastating choices.

During committee testimony, we heard from multiple witnesses about Canadians who were forced to choose between paying for their medications or for the basic needs of life. We heard from the Canadian Labour Congress that 1 million Canadians are taking out loans to pay for their medication. Bill C-64 covers diabetes drugs and contraceptives and related products. Without a doubt, many would wish for more. I wish for more. But in covering these two classes of drugs, we are making a substantial difference in the lives of millions of Canadians and their families.

For diabetes, the physical cost of not adhering to your prescription is dire. Experts in committee noted that 40% of all heart attacks in this country come from diabetes, and it’s 30% of all strokes. These are shocking numbers. They spoke to the risk of blindness, kidney failure or the loss of limb — complications that could be significantly reduced and avoided with established access to the right medications early in the course of one’s illness.

When it comes to contraception, witnesses pointed out that 40% of pregnancies each year are not planned. We heard that many of those who are impacted by the lack of access to contraceptives, and other family planning tools, are more likely to live in poverty, less likely to be employed full-time and more likely to rely on public assistance. For children, they are more likely to live in poverty and face developmental challenges.

Colleagues, the status quo is not working. This change is long overdue. This is why I accept a step-by-step approach because any step in the right direction is better than standing still while Canadians suffer.

Advocates and individuals — Canadians — are all calling for this bill to pass as is and without delay. We have heard from unions, advocacy groups and everyday Canadians, not only through committee testimony but also through letters and emails, and I’m sure many of you have received these communications.

This is not just an abstract policy debate. This bill responds to the lived realities of millions of people in Canada who are depending on us to take action. This does not mean that passing Bill C-64 is the final step. It cannot be. Our work is not over. We must push to achieve the end goal which is a universal, public, single-payer system, and we have a long way to go before we get there.

Crucially, this bill takes action on a few key next steps. It calls for Canada’s Drug Agency to create a list of essential prescription drugs and related products within a year of Royal Assent. This will be a vital step toward the creation of a national formulary, which is a comprehensive evidence-based list of prescription drugs and related products that Canadians would have access to in a national universal pharmacare system.

Colleagues, this will require extensive engagement with provinces, territories, Indigenous communities, drug manufacturers and patients.

Bill C-64 also calls for Canada’s Drug Agency to develop a national bulk purchasing strategy for prescription drugs and related products. An effective bulk purchasing strategy could lead to big savings when it comes to the cost of providing access to medication in Canada.

In committee, we heard from Dr. Steve Morgan who noted that there is a lot of buying power in being a single payer. He gave an example comparing prices in Canada and New Zealand, which has a single-payer public pharmacare program. Looking at the top 32 generic drugs sold in Canada, he found that if we paid what New Zealand pays, we would save $770 million a year on just those 32 drugs.

This first step toward a pharmacare system is important, but there is still a long road ahead, and there are several challenges. One of these challenges will be countering those who seek to send us down another path. In the hopes of protecting their own financial interests, some have erroneously argued that pharmacare would stunt access to new drug medicines in Canada. Well, colleagues, a report from the Patented Medicine Prices Review Board found that 79% of drugs introduced between 2013 and 2022 provided slight to no improvement over existing drugs, but made up over 60% of the revenue share.

This highlights the caution that not all drugs provide good value for money or should be included in a pharmacare formulary. Rather, pharmacare means that we will be more likely to purchase drugs that have the highest value for the best cost.

It should be noted that the list of drugs and related products covered is not really in this bill, which allows for future changes to the list without legislative amendment.

Similarly, we have heard concerns from some that this bill will negatively impact private insurance. Well, yes. Some have suggested that insurers will scale back their coverage or employers will choose to remove coverage for areas covered by Bill C-64. Others have called for constraints to ensure that insurance companies don’t remove coverage of contraceptives and diabetes medication.

Colleagues, it’s important to note that the regulation of the market conduct of insurance companies is a provincial responsibility, not a federal one. Every province has a provincial act responsible for the regulation of insurance in their province.

I would say there are negotiations to be had at the provincial level and conversations to be had between employers and their employees, as well as between unions and their members. This bill is an opportunity for them both.

We heard from union representatives that this bill is an opportunity to negotiate for better coverage. If there are savings for employers due to the government covering these selected medications and products, this will give them the freedom of choice to expand coverage in other areas, leading to even further benefits for their employees.

Let me be clear, private insurance is not the solution to the lack of access to drugs many Canadians face; universal pharmacare is.

This bill is the beginning, not the end. It’s a floor, not a ceiling. Provinces can improve on this and include other medications. While it may not be everything we hoped for immediately, it is a foundation upon which we can build. It is the first step toward a Canada where no one has to worry about whether they can afford their medications that will keep them healthy.

As a physician who has seen far too many of my patients and their families struggle to maintain their health needs due to high drug costs, and as a woman who has seen the impact that access to reproductive choice in family planning can have on women’s lives, I’m proud to see Canada make this important step.

For that reason, colleagues, I urge you to join me in supporting Bill C-64. Thank you. Meegwetch.

Some of us from Saskatchewan received a letter from the Saskatchewan Chamber of Commerce about this issue, Bill C-64 and their concerns with it. A couple of the statistics they quote in the letter are that currently about 90% of mid- to large-sized employers and about 70% of small businesses offer prescription drug benefit packages to attract and retain employees. They also indicate in this letter that the recent estimates that they have put the number of uninsured at about 2.8% of Canada’s population.

With those numbers that have been provided from the Saskatchewan Chamber of Commerce in mind, one thing I’m wondering about is the part I heard in your speech where you were talking about the private drug plans and that that would essentially be a matter for negotiation with provinces, et cetera. Sometimes people who are of lower income, they may have those drug plans, and maybe the main benefit they get out of those employer drug plans is coverage for these prescriptions that are being covered under Bill C-64. Did you hear any evidence about whether their premiums for those types of workplace drug plans would potentially be reduced given that the federal government would be paying it under a single-payer plan?

Thank you, Senator Batters.

In fact, we did not have true representation of small businesses at committee. We had chambers of commerce, but they really took the position of talking about, in my opinion, primarily their clients who are insurance companies.

In fact, some of my questions to them challenged them to say, “What, in fact, is your position for small businesses?” Because many of us — and maybe yourself — have heard from small businesses that there are different ways they might approach this. There are new opportunities that this might present for them.

No significant data was provided. In answer to your question and, in fact, to some disappointment from my perspective, the chamber of commerce witnesses did not actually give us more of a perspective that was different from protecting insurance companies.

Honourable senators, I rise today at third reading to express my concerns about Bill C-64, An Act respecting pharmacare.

As you may have noticed since my arrival in the Senate nearly three years ago, it isn’t customary for me to oppose government bills. Today, I’m doing so both as an economist and as a former minister in the Quebec government. It is true that I was unable to take part in the work of the Standing Senate Committee on Social Affairs, Science and Technology because of scheduling conflicts with the committees I am part of. Nonetheless, I was able to watch the recordings of all of the committee’s meetings devoted to this bill’s analysis.

The first reason for my discomfort relates to my vision of federalism, which was influenced by my time in provincial politics alongside former Liberal premier Jean Charest. He was a true progressive in the noble sense of the word, but also an ardent federalist and advocate of decentralized, asymmetrical federalism. I, too, believe in asymmetrical federalism, where the economic and social priorities of one province may differ from those of another.

I have no problem with the fact that Quebec’s pharmacare plan provides different coverage than Manitoba’s, or that Quebecers have to pay a different annual deductible than their Ontario counterparts. I have no problem with the fact that the minimum age for consuming alcohol in a bar or the age for obtaining a driver’s licence may be different in Quebec than it is in Ontario or Alberta.

As you can see, I don’t agree with this new intrusion by the federal government in the way that health care is provided across Canada.

Because they are closer to the people, I believe that the provinces and territories are in a much better position than Ottawa to meet the needs of our fellow citizens when it comes to education and health care, including through their respective pharmacare plans. In fact, the Quebec National Assembly unanimously condemned Bill C-64 and demanded what is known as “the unconditional right to opt out with full financial compensation.”

In Quebec, the Régie de l’assurance maladie du Québec already covers over 8,000 prescription drugs in various strengths and dosages.

Quebec is recognized as a forerunner in the country, since it introduced its pharmacare plan in 1997. Over time, the plan was improved to ensure that everyone is covered in return for a maximum annual deductible, which is $1,200 in 2024. However, it is important to note that prescription drugs are free in Quebec for vulnerable groups, such as people on welfare or seniors receiving the maximum Guaranteed Income Supplement.

Honourable colleagues, I mention this, not to ignore the thousands of Canadians outside of Quebec excluded from this different provincial pharmacare plan. I certainly understand why many of you look positively upon Bill C-64. I’m not here to judge you. I understand.

I will, however, invite you all to ask yourself a few questions: How far will this top-down federalism go? Is the next step to put in place a new federal program taking care and responsibility for the country’s homeless, offering each of them accommodation under the pretense that our cities and our provinces are unable or are not interested in taking care of all of them?

As progressive senators, I’m entirely on board with helping those in need, but I cannot agree with the approach of this current government, whose governance mirrors the NDP-centralized vision of Canadian federalism.

Members of the Standing Senate Committee on Social Affairs, Science and Technology have probably noticed that the NDP has an outsized influence in the drafting of Bill C-64. During Minister Holland’s testimony, the minister’s maneuvering room in accepting amendments was next to none, as he risks losing NDP support in the other place.

By the way, we can expect to see the same friendly government pressure in force when debating Bill C-282 on supply management because a refusal or adoption with amendment by the Senate could also risk bringing down the government.

Honourable senators, I don’t deny that Ottawa certainly has a say in health care. That’s what the federal government did after the Second World War, when it adopted a 50-50 cost-sharing formula for health transfers and social programs until the mid-1970s.

After that, the rules of the game began to change gradually when the federal Established Programs Financing program was adopted in 1977. That program abandoned the 50-50 cost-sharing formula in favour of a fixed annual per capita payment to the provinces. Then the Canada Health Act, with its five eligibility criteria, was adopted in 1984.

I remember that very well. Why? Because, at the beginning of my career, I was a civil servant with Quebec’s finance ministry, working in the federal transfers and fiscal arrangements division. So I know what I’m talking about.

More specifically, the federal contribution to public health spending in Canada has gone from a 50-50 cost-sharing formula until the mid-1970s to a fixed per capita contribution, which now stands at a low of 22% of public health spending in Canada borne by the federal government. However, with the recent renegotiation, which took place in 2023, these expenditures are now closer to 25%. So we’re a long way from the 50-50 cost-sharing formula of the early 1970s.

In my humble opinion, when the federal government handles only 25% of the bill for health spending, Ottawa should be less critical and show some humility before encroaching on provincial jurisdiction with new initiatives. As long as it contributes less than a 50% of Canada’s health spending, the federal government’s involvement in drug coverage should be limited to its current approval role, as the U.S. Food and Drug Administration does south of the border.

Besides my opposition to the duplication of responsibilities with the provinces, my second concern — I’m now wearing my economist hat — is financial, and it concerns the real costs associated with implementing universal public pharmacare.

While it’s true that the Office of the Parliamentary Budget Officer’s report indicated a figure of $1.9 billion over five years for the cost of the pharmacare program, which covers diabetes and contraceptives only, Mr. Giroux made it clear to the Senate Standing Committee on Social Affairs, Science and Technology that this didn’t take into account any drug substitution effect and that people would retain their current coverage with insurance companies.

Let’s just say I have my doubts. Having worked in the insurance field, I don’t believe that is what will happen. We can expect the cost of the new system to reach a minimum of $4.3 billion over five years, not $1.9 billion. The cost will increase gradually as the number of drugs covered grows.

Some witnesses mentioned possible savings on the price of drugs with the introduction of the national pharmacare plan, and better leverage with pharmaceutical companies. Once again, I’m skeptical. A Canada-wide negotiation mechanism, created by the provincial and territorial premiers in 2010, called the pan-Canadian Pharmaceutical Alliance, or pCPA, was set up to ensure that government pharmacare programs would give patients more value for their money, and that the price of a given drug would be uniform from province to province.

Dominic Tan, deputy CEO of pCPA, explained that the organization negotiates prices that apply nationwide. He said the following:

Our mandate is to negotiate for drug prices on behalf of the public drug plan for the entire country. What that means is our mandate is actually provided by our members. That being said, certainly we are eager to learn more about what bulk purchasing means because we certainly welcome effort to collaborate with our partners.

We are not yet clear on the details of bulk purchasing as stated within the bill currently. That’s what we need to better understand and collaborate with our partners on . . . .

In other words, the jury’s still out. Furthermore, how would the administration of the existing drug plan by the Régie de l’assurance maladie du Québec and Quebec pharmacists be affected if the federal government were to cover dozens or even hundreds of other drugs in three years’ time? That would certainly be a challenge.

It seems to me that our government’s current priorities should lie elsewhere. The latest report from the Fraser Institute, released last Friday, showed that the median salary of all 10 provinces in Canada is now inferior of those seen in every state in the U.S., including Louisiana and Alabama. Can you believe it? It’s hard to believe.

I would humbly suggest that the government focus more of its attention on wealth creation; otherwise, we could easily — in 10, 15 or 20 years — follow the same path and experience the same fate as Argentina and Greece.

Honourable senators, I will conclude by reiterating how uneasy I feel about this bill, even though it is full of good intentions. I understand that people see this bill differently depending on whether they live in Quebec or in another province. However, this bill is inconsistent with my vision of an effective, decentralized federalism that is concerned about avoiding overlap and duplication with the provinces.

For all of these reasons, I intend to vote against the bill. Thank you for your understanding. Meegwetch.

Senator Gignac, your time has expired. Are you asking for more time to answer the question?

Yes.

Is leave granted, honourable senators?

That’s a very good question, senator. While I don’t wish to appear insensitive on this issue, I wonder if it’s really here in Ottawa, in the House of Commons and the Senate, where the battle should be waged. If people are dissatisfied and want the deductible to be lower or even free, that debate needs to happen in the provincial legislatures. It’s just that I don’t know how far this will go. I mentioned the least fortunate and the homeless, and the same thinking applies. It might well go that far.

I think that, instead of debating this issue here, I’d be inclined to say that pressure should be brought to bear on the provinces.

Honourable senators, I rise to speak very briefly on Bill C-64, An Act respecting pharmacare.

I wish to thank the sponsor of the bill, Senator Pate; the critic, Senator Seidman; our committee members; and the many witnesses who shared their wisdom and perspectives with us at committee.

Like many other legislative proposals, this bill is not perfect; in fact, it has more than its share of imperfections. There are too many ambiguities, too many words that are not anchored in any definitions, there are issues with costing, there is uncertainty about what agreements with provinces will look like and debates about whether this bill will take away benefits from individuals instead of guaranteeing them.

And yet, colleagues, I fully support this bill because I see what it will do for the lives of poor people, families who have no coverage or families and individuals who may have coverage through their employers but who cannot afford either their premiums that they must pay or the copayment that is attached to accessing drugs prescribed to them.

The numbers are not small. The Conference Board of Canada told us that 3.7% of Canadians do not have any coverage for drugs of any kind. The only time they get free drugs is when they are hospitalized. Another 7% are uninsured because they cannot afford to pay for the premiums for drug coverage at their place of work, which amounts to close to 10% of our population. That is a serious number, colleagues. It’s an extremely serious choice for the parent of a child who is diagnosed with diabetes who must make a very difficult choice — an impossible choice — between buying medication or paying rent.

That is not an isolated case; it is a harsh reality for many. Nearly 60% of Canadians living with diabetes report difficulty adhering to their prescribed therapies due to the costs of medications and supplies. We heard at committee that, more often than not, the cost of drugs is so high that people simply cannot afford to access them, even with insurance coverage.

I will give you an example of a nurse from Saskatchewan, who is definitely not a poor person, with two adult children at home suffering from diabetes. She is covered through insurance at her work, but the medications are so expensive that the co-insurance payments were beyond her means. As a result, her daughter is not able to go to university, and her son is not able to hold a job because those medications were out of their reach.

That is just one anecdote, but remember the number: 60% of Canadians living with diabetes face an affordability crunch. The impact is horrendous. Not adhering to treatment plans results in severe complications that affect individual health and place enormous strains upon our health care system. Consider the increased costs to the individual and the system of emergency room visits and hospitalizations. Let’s consider the mental health ramifications of financial stress on individuals and their families, which impact not just their physical health but also their mental resilience.

In addition, we heard that this is particularly troubling for groups that are already marginalized. Ms. Laura Syron, President and CEO of Diabetes Canada, said that socio-economic status and socio-economic factors play a big role in higher rates of diabetes for marginalized groups but so do environmental and genetic factors. She stated that, increasingly, we are seeing that the mental health impact of diabetes is a burden carried more by some groups than by others. I think we all know which groups she’s talking about: racialized people, Indigenous communities, et cetera.

Let me address briefly the issue of cost. The Parliamentary Budget Officer has indicated that Bill C-64 will increase expenditures by $1.9 billion. Senator Gignac said it could be as high as $4 billion, but I think the truth is somewhere in the middle. I grant that there will be an initial public investment that will be costly, but there will be savings, too, arising from fewer hospital visits and emergency room admissions as well as savings arising from the availability of diabetes and contraceptive medication.

There hasn’t really been a balance sheet for costs and savings, but this represents more than dollars and cents; it represents and embodies improved lives, supported families and brighter futures.

The lack of universal coverage for contraceptives also has serious implications. Nearly half of all pregnancies in Canada are unintended, leading to decisions sometimes filled with joy — I think we should acknowledge that — but sometimes filled with emotional and financial strain. Women and young girls find themselves faced with difficult choices on abortion, adoption or raising a child without adequate support.

The ripple effect of the lack of access to contraceptives has a very long tail. It can lead into the next generation, which likely will need to access public assistance supports.

We are also outliers when we compare ourselves to other like‑minded jurisdictions in the Organisation for Economic Co‑operation and Development, and we have a lot of catching up to do.

So while I recognize that this bill has its challenges, particularly regarding definitions, clarity and provincial jurisdictions, I am encouraged that this is the first of many steps to take. I believe in incremental improvements. Nothing before us that I have seen here has ever been perfect. It is important for Canada to now take the first step because the first step is always the most difficult to take.

I urge you — in fact, I believe it is incumbent upon us, in the interest of poor people in Canada — to take this first step and support this bill. Thank you very much.

Will Senator Omidvar take a question?

Yes, thank you. I will.

Thank you, senator. My question is in regard to a statistic that you mentioned in your speech.

I believe you said that 2.8% of Canadians do not have any type of insurance to cover the cost of their prescription medications. That is a figure we heard at the Social Affairs Committee. Again, it was a Conference Board of Canada report in which they said that 97.2% of Canadians have access to prescription drug coverage, which is why, in my speech, I referenced a Statistics Canada report in 2022 that said that 21% of Canadians reported no insurance as opposed to that Conference Board of Canada report, which quotes only 2.8% of Canadians not having access to insurance.

My question for you is this: Were you aware that funding for that Conference Board of Canada report came from the national association that represents Canada’s innovative pharmaceutical industry?

We have different figures. The figure I have from the Conference Board of Canada is 3.7%. We checked it. I did not know that the funding for that report came from Innovative Medicines Canada. They testified before us.

I don’t think we’re coming at this from different angles. My point was just that this report, which has been used quite a bit, was put out by The Conference Board of Canada, but it had different funding. My question was whether you were aware that this was where the funding came from, which is why in my speech I chose to use the Statistics Canada data. It sounds like you’re aware of it.

That’s not a question, but agreed.

Will the senator take another question?

Yes.

Thank you, Senator Omidvar, for your speech, particularly the part about an important first step that’s going to be addressing those in our country who can’t afford access to drugs today. I think that’s a very important issue.

In moving forward with the bill and during all of the hearings that you and your committee held, are there any gaps we’re creating in any way that might affect those who are currently covered by insurance plans so that by looking after one segment — a very important segment — we create a gap in another area, even if it’s a temporary gap while negotiations happen. Are there any gaps that you feel may be created even on a temporary basis?

I’m not sure about the gaps. We did hear about gaps, Senator Quinn, especially in the first rollout, but I’m not quite sure whether I know of any particular gaps. We did hear that when the formulary is rolled out, it is possible that certain individuals who are covered by their private health care will see those drugs moved out or be covered by the government. I think there will be start-up problems. I accept that.

Honourable senators, I rise today in support of Bill C-64, An Act respecting pharmacare. I thank Senator Pate for doing such an amazing job of sponsoring this bill.

This bill is an important step toward establishing a universal pharmacare plan that will save lives by improving Canadians’ health while reducing costs to our health care system.

According to the 2019 final report of the Advisory Council on the Implementation of National Pharmacare, one in five people, or 7.5 million Canadians, have no drug insurance or insufficient coverage to adequately cover the cost of their medications.

Senators, this is our constitutional responsibility. We must defend the vulnerable groups who are least likely to have access to a drug insurance plan, including Indigenous people, immigrants and racialized groups. It would therefore seem appropriate for the government to take steps to remedy this major shortcoming. To achieve this objective, Bill C-64 is based on the four guiding principles set out in clause 4: accessibility, affordability, universality and appropriate use.

Colleagues, did you know that a survey done this year by the Heart & Stroke Foundation and the Canadian Cancer Society showed that over one in four people in Canada have difficulty paying for their prescription drugs? Almost one-quarter of Canadians say they split their pills, skip doses, or choose not to fill or renew their prescription because of the cost; over one in four people has had to make hard choices to afford prescription drugs, like limit their groceries, delay paying their rent, mortgage or utility bills, and take on debt.

These figures offer insight into failings in our health system that need to be remedied through Bill C-64.

As Minister of Health Mark Holland said in his evidence before the Standing Senate Committee on Social Affairs, Science and Technology, Bill C-64 would allow us to “receive free access, without co-pay or deductible, to a range of contraception and diabetes medications.”

Affordability and accessibility are inseparable. For a product or service to be truly accessible, it has to be financially affordable as well. If drugs or health care are available but financially out of reach for a portion of the population, their accessibility becomes limited or nonexistent. In 2015, for example, one in four Canadians with diabetes said that their compliance with treatment depended on its cost.

Access to prescription drugs must be based on medical need, not ability to pay. My 35 years of experience in family medicine and my particular expertise in diabetic foot problems mean that I can assure you that poorly controlled diabetes often leads to serious complications, ranging from heart attacks to amputation to blindness. These situations exacerbate systemic inequalities. As previously mentioned, it is the most marginalized who suffer the most serious consequences. In fact, according to the Conference Board of Canada, 5% to 8% of leg amputees are homeless. If this bill isn’t passed, health inequalities will remain. They would be a sword of Damocles for nearly one million diabetics who, according to the Canadian Institute for Health Information, are at risk of suffering a serious complication.

Until now we’ve been talking about the cost of drugs. I haven’t heard much talk about the human and social costs. This is about people in the workforce who had a stroke, suffered an amputation, or went blind. What happens to their lives then? Our emergency rooms are overflowing, because we don’t have enough prevention. These patients aren’t getting the right drugs. According to a report by the Canadian Institute for Health Information, more than 30,000 hospitalizations every year are directly related to complications of diabetes in the lower limbs. These hospitalizations have cost more than $750 million a year. I’m talking about diabetes because that concerns Bill C-64, but in reality, any chronic illness poorly managed because of a lack of drugs or other reasons will lead to complications in the medium or long terms.

Colleagues, I haven’t yet talked about the emotional and financial toll that weighs on caregivers. In many cases, they themselves are in the workforce and end up forced to leave to take care of their sick loved one. I had the opportunity to accompany patients and their caregivers in my home care medical practice. I can attest to their suffering, their sense of guilt and their distress.

Access to health care in Canada has to remain a universal and fundamental right in a fair and just society.

As the Minister of Health mentioned, this bill is a first step that the Government of Canada is taking to achieve more extensive coverage. Since health administration is a provincial responsibility, its next challenge will be to work closely with the provinces and territories to reach bilateral agreements. This would ensure that public health policies meet the real needs of populations, while taking the specific circumstances of the provinces and territories into account, as we heard at the Social Affairs, Science and Technology Committee. It’s not up to us to dictate the terms of these agreements between governments. I want to congratulate British Columbia, which signed a memorandum of understanding with the federal government on September 12, 2024.

I’d also like to highlight an example related to Bill C-35, Canada’s Early Learning and Child Care Act. When it was passed, Quebec already had a public network of quality early learning and child care services and a reduced-contribution spaces program. Its specific needs were taken into account in the 2021-26 agreement reached with the federal government. Article 5 of the agreement reads as follows:

 . . . Quebec intends to use a significant portion of the contributions made under this agreement to fund further improvements to its early learning and child care system . . . .

As a proud Quebecer who was there when Quebec implemented its public drug plan in 1997, I can attest to its effectiveness, even though the system still has many challenges to overcome.

This treasured Quebec program has shown that it is possible to provide drug coverage for the entire population while guaranteeing equitable access to care and medication.

As for the critics who cited the higher cost of this plan, you must understand that it covers more than 8,000 drugs. It has been helping to reduce inequality and improve Quebecers’ quality of life for over 25 years.

In conclusion, today we have the opportunity to establish a pan-Canadian drug plan. Let’s take this opportunity to pass Bill C-64 without amendment, so as not to leave 7.5 million Canadians without drug coverage. It’s a question of fairness.

Thank you.