Moved third reading of Bill C-64, An Act respecting pharmacare.

She said: Honourable senators, together, today, as we launch the final phase of our discussions on Bill C-64, An Act respecting pharmacare, we are part of a landmark first step toward a national, universal, public, single-payer pharmacare system for Canada. Bill C-64 will improve access to affordable prescription drugs, starting with universal, single-payer access to essential contraception and diabetes medications.

Given the purpose of this bill, I feel compelled to acknowledge and thank our friend and colleague Senator Lankin for her life’s work. Every job, but especially when she was Ontario Minister of Health, was a testament to her commitment to advancing national, universal pharmacare.

Senator Frances Lankin, P.C., is preparing to embark on the next stage of her life’s journey. What more fitting way to end her time in this place than by seeing this bill through? We are all happy that she is here and that maybe she will even speak to Bill C-64 before we vote on it.

I know I speak for many when I tell her how very grateful we are for her years of generous service, informed by her thoughtful wisdom, guidance, advice and friendship.

I want to read into the record a very heartfelt chi-meegwetch. Thank you, Senator Lankin, for all you are and all you do.

To underscore what this bill means to Canadians, I will first focus on three particularly Canadian achievements. First, in 1921, insulin was discovered by Banting, Best and Macleod at the University of Toronto. It is only fitting that diabetes medications will be among those offered in Bill C-64’s first stage of national pharmacare. This inclusion represents not only a significant step forward for the health of countless Canadians struggling to afford diabetes treatments, but is also a reminder of Banting’s principled refusal to profit off of people’s need for life-saving medicine. He refused to be a part of patenting insulin, considering it unethical to do so. His two colleagues did follow through with a patent, but they sold that patent to the University of Toronto for $1 so that the medicine could benefit all.

As sponsor of Bill C-64, I’ve had the privilege of discussing this legislation with many colleagues in this place, across groups and regions and with international experts, as well as with many others in interrelated areas of expertise. In addition to the significant steps that will commence with the passage of this bill, this legislation has highlighted other challenges to public access to vital medication. A significant one is the monopolistic and opaque area of drug pricing and related access issues.

While the ability to patent may be an important aspect of business development in this and other areas, as our friend and colleague Senator Colin Deacon so clearly and succinctly put it when I consulted him on this issue:

Patents are government-granted monopolies . . . at a certain point, governments may find themselves wondering whether that government-granted monopoly is serving the public interest.

Pharmaceutical profiteering is a beachhead that we must also address. Primarily because of astronomical drug prices, Canadian households and employers spend some eight times more per capita on medicines than our counterparts in jurisdictions with single-payer pharmacare systems that are publicly administered and that limit incentives for private profits at odds with the public good.

As Canada takes its first steps toward national pharmacare, Banting’s legacy must be our reminder of the imperative of putting public interest above all else and the need to continue to do more on this front, so yes, we will still have much to do even after this bill passes.

Next, I want to highlight the importance and impact of the achievement of the 1948 proclamation of the Universal Declaration of Human Rights by the General Assembly of the United Nations. Though undoubtedly an international achievement, Canadians are proud to know that the principal author of this foundational text, which continues to inform and shape Canada’s understanding of human rights, was Canadian legal scholar and human rights advocate John Peters Humphrey.

Article 25(1) of the declaration enshrines:

. . . the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care . . . .

As parliamentarians, we have witnessed a groundswell of support from people across Canada who are awaiting national universal pharmacare. To do justice to those in our regions — whom we are in Ottawa to represent — let us never lose sight of the reality that Canadians advocating for pharmacare are not merely appealing to us for our empathy or our sense of reason, they are rightfully claiming their entitlement to their human right to health.

The third Canadian achievement I invoke today is the passage, in this very Senate chamber, of legislation implementing Canada’s universal medicare system in 1966. For six decades, medicare has stood for the embodiment of our shared values and collective commitment that access to health care should not depend upon the amount of money in one’s pocket or bank account. Every person in this country — all of us — have a right to health care.

What is today often considered foundational to Canada’s identity was far from a sure thing at the time it was being legislated and debated. The road to medicare was a winding one. Implementation involved many bumps and curves, from seemingly endless hesitations to a multitude of questions as to whether this was a cost Canada could afford. It also included tenuous cooperation between two federal parties in a minority Parliament. Sound familiar? It also involved crucial leadership from a province with a bold vision that helped move all of us forward, sometimes seemingly against all odds.

Today, although Canada dines out internationally for our reputable health system, absent this current legislative step, we remain the only country in the world to provide universal health care but not universal pharmacare.

Bill C-64 puts us on the path to fill this historical gap. As we do so, Canada’s history with medicare should give us confidence in the principles that shape Canada’s health system. These principles are public administration, comprehensiveness, universality, portability and accessibility. A pharmacare system in line with these principles is not out of reach or out of touch. It is what Canada has needed for decades.

As we have heard from our discussions in this chamber, Bill C-64 is foundational legislation that lays out key principles that will guide the government’s efforts in collaborating with Indigenous peoples, provinces, territories and other partners and stakeholders on the step-by-step implementation of national universal pharmacare.

Clause 4 emphasizes four key principles: accessibility, affordability, appropriate use and universal coverage. As outlined at second reading, these principles are critical for ensuring Canadians, particularly marginalized groups and those populations made vulnerable by all manner of circumstances, can access the medicines they need. The bill’s preamble further acknowledges that this incremental process is to be:

. . . guided by the Canada Health Act and carried out in accordance with the recommendations of the Advisory Council on the Implementation of National Pharmacare;

The 2019 recommendations of the advisory council, also known as the Hoskins report, provide a blueprint for implementing a national pharmacare plan. The Hoskins report takes as its central premise that pharmacare can improve access to necessary medicines for all Canadians while also saving costs if implemented as a universal, public single-payer system.

It is no secret that Canada is struggling to ensure and secure meaningful access to medicines for the Canadians whose health and lives rely upon them. The primary reason for this higher spending is high drug prices. Internationally, drug purchasing is based upon public and private insurers negotiating confidential rebates from drug manufacturers off often exorbitant publicly listed prices. This cloak of secrecy makes it inordinately difficult, especially for smaller purchasers, to get a fair deal. Allowing Canada’s public drug plans to join forces to provide single-payer coverage of carefully selected medications should help increase transparency and bargaining power, and could effectively lower drug prices in a way that Canada’s current patchwork mix of public and private plans simply cannot. We must therefore persist and resist pushes to privatize and commodify the process.

From the outset, the program will need the buying power of a single-payer system purchasing medications for 40 million Canadians through processes that are evidence-based and publicly accountable. In addition to lowering costs for medications, this should streamline system complexity and administrative costs.

The Hoskins report recognized that a robust single-payer system cannot be built overnight, recommending, instead, an incremental or “stepwise” approach beginning with coverage of some medicines and expanding into a more fulsome program.

Bill C-64 reflects that approach to the implementation of national pharmacare. It lays the groundwork for universal single-payer coverage of essential contraceptive and diabetes medications. It also tasks the newly formed Canada’s Drug Agency with the development of a broader national formulary of essential medicines and a bulk-purchasing strategy that could help form the next step for universal single-payer coverage.

I also want to speak today specifically about work with provincial and territorial governments on this first phase of access to contraceptive and diabetes medicines. As we know, the governments of Indigenous peoples, provinces and territories have key roles with respect to the delivery of health care services, and every jurisdiction has different needs and faces different challenges in delivering those services. That is why Bill C-64 recognizes that federal efforts towards national pharmacare require a cooperative approach with Indigenous peoples as well as each province and territory to help ensure that no one is left behind. Bill C-64 outlines that any funding to provinces and territories to support pharmacare will be provided through bilateral agreements. The bill further provides that this funding will be in addition to existing provincial and territorial spending on public drug benefit programs.

Bill C-64 likewise emphasizes the government’s commitment to collaboration with Indigenous peoples, highlighting in particular the need for discussion with Indigenous partners in the context of developing a national formulary. At the Social Affairs Committee, Minister Holland reaffirmed that Bill C-64 will not interfere with existing coverage of medicines for First Nations and Inuit peoples under the Non-Insured Health Benefits program and stressed that Bill C-64 can provide the opportunity to further build upon and expand coverage for Indigenous peoples.

I also want to remind you that collaboration with provinces and territories, as outlined in Bill C-64, is already under way with other initiatives that will inform the path forward on national pharmacare.

That includes federal efforts to make drugs for rare diseases more accessible. The Government of Canada launched the first-ever National Strategy for Drugs for Rare Diseases in March 2023, with an investment of up to $1.5 billion over three years. As part of the overall $1.5 billion investment, the federal government will make available up to $1.4 billion over three years to willing provinces and territories through bilateral agreements. This funding will help provinces and territories improve access to new and emerging drugs for Canadians with rare diseases, as well as support enhanced access to existing drugs, early diagnoses and screenings for rare diseases. That will help ensure patients with rare diseases have access to treatments as early as possible in order to enjoy a better quality of life.

In addition, as part of the national strategy, just over two months ago, on July 23, the first bilateral agreement was announced. The Government of Canada will be providing $194 million over the next three years to the Government of British Columbia to help provide access to the drugs patients need to treat their rare diseases and to reduce the financial burden on their families.

Another example of the federal government’s ongoing work with provinces and territories can be found in the pharmacare demonstration initiative in partnership with Prince Edward Island. This initiative was announced in August 2021 and represents a concrete example of how the principles of improving accessibility and affordability of prescription drugs can make a difference in the lives of Canadians. Under this agreement, P.E.I. is receiving $35 million in federal funding to improve access to and make prescription drugs more affordable for Islanders. P.E.I. was selected to participate in the demonstration initiative because its residents face some of Canada’s highest out-of-pocket expenses and the country’s most limited formularies.

Since the beginning of the initiative, P.E.I. has used federal funds to expand its list of covered drugs and help Islanders save money on their prescriptions.

For example, in June 2023, P.E.I. reduced copays to only $5 for almost 60% of medications regularly used by Island residents for cardiovascular disease, diabetes and mental health, which are covered under several public drug programs. To date, Islanders have saved over $6 million in out-of-pocket costs through this initiative.

P.E.I. has also expanded access to over 100 new medications to treat a variety of conditions, including cancer, heart disease, migraine, multiple sclerosis, pulmonary arterial hypertension and psoriasis.

As I heard when I visited and met with folks on the Island, the P.E.I. pharmacare demonstration initiative has provided real results, and Bill C-64 will do the same, starting us on the path toward universal pharmacare with a free, single-payer plan for contraception and diabetes products whose costs are publicly funded and publicly administered. It lays the groundwork for Canada to finally deliver a pharmacare system on par with the principles enshrined in our medicare system.

Once passed, Bill C-64 will bring relief to Canadians who struggle to pay for necessary medications, starting with women and gender-diverse people of reproductive age and people living with diabetes. In 2021, Statistics Canada found that one in five adults in Canada did not have the insurance they needed to cover their medication costs. That is close to 8 million Canadians without the necessary insurance to obtain the prescription drugs they need.

Unfortunately, this gap means that every month — sometimes every week or day — millions of Canadians have to make the difficult choice between paying for their prescriptions or covering essentials like food or heat. It also results in too many Canadians seeking emergency medical attention because they are unable to afford their medications — some because they have gone without and others because they rationed their doses to try to make ends meet.

I am confident that from our place of relative privilege, we all agree that every Canadian should have timely access to the health care they need, when they need it, regardless of their ability to pay.

As part of the first phase of national pharmacare, access to contraception and diabetes medications at no cost will benefit both the health of Canadians and the health care system.

Coverage for contraceptives will mean that 9 million Canadians of reproductive age will have better access to contraception and reproductive autonomy, reducing the risk of unintended pregnancies and improving their ability to plan for the future.

Currently, coverage for contraceptives varies across the country. Most Canadians rely on private drug insurance through their employer for their medication needs. Even so, most drug coverage plans only cover a portion of the cost, with the remainder paid out of pocket by the patient.

Some people are disproportionately affected by a lack of coverage. Women, people with low incomes and young people are all more likely to work in part-time or contract positions, often lacking access to private coverage. Without private insurance, drug coverage often involves out-of-pocket costs for the medications they need.

A discussion with a young woman earlier this week reminded me that too many girls and women whose parent, guardian or partner might provide them with entitlement to a private drug plan may actually lack access to contraceptives if the person whose plan that they need to access opposes their wishes. For these folks, access is simply not an option.

Cost has been identified by Canadian contraceptive care providers as the single most important barrier to accessing contraceptive medications or devices. For too many young women working part-time jobs without drug benefits, accessing an IUD or other effective contraceptive methods while trying to manage other basic life expenses, such as rent or grocery bills, is simply impossible.

Bill C-64 will ensure that Canadians have access to a comprehensive suite of contraceptive drugs and devices and that they will have the ability to choose which form of contraception is the most appropriate for them.

When it comes to managing diabetes, existing drug coverage for medications and supplies varies widely across Canada, leaving many Canadians underinsured. Underinsurance can take many forms. For example, for a working-age Canadian with no private insurance, public drug plan costs can vary widely. In some parts of the country, out-of-pocket costs for people living with Type 1 diabetes can be higher than $18,000 per year, and for Type 2 diabetes, it can be higher than $10,000 per year.

Even those with private insurance can face copayments of 20% or higher, exceed annual plan maximums or reach lifetime coverage limits. It is too often Canadians with the least who are left to try to pay these untenable costs for essential medicines out of their own pockets.

Underinsurance can be a particular concern for young adults with Type 1 diabetes who age out of their parent’s private insurance but do not have their own form of private coverage.

Lower-income Canadians also make up a disproportionate share of the underinsured. While most provinces have put in place drug coverage for those accessing social assistance, too many lower-income households that do not qualify for social assistance continue to struggle with out-of-pocket prescription drug costs.

Employment factors can also contribute to differences in insurance coverage. People who work in gig work or entry-level, contract, seasonal or part-time positions often report less adequate drug insurance coverage. This often discourages people accessing social assistance from applying for jobs. Why? Because once hired, they could lose their public drug coverage without receiving drug benefits or a livable income adequate to cover the costs of the medicines they need.

One in four Canadians living with diabetes has reported not following their treatment plan due to cost.

Removing barriers to diabetes medications will help improve the health of many of the 3.7 million Canadians living with diabetes, as well as reduce the risk of serious, life-changing — and life-threatening, in some cases — health complications such as blindness or amputations.

Beyond helping to support people in managing their diabetes and living healthier lives, if left untreated or poorly managed, diabetes can lead to high costs on the health care system due to complications including heart attack, stroke and kidney failure. Diabetes Canada estimates that by 2028, the full cost of diabetes to the health care system could be almost $40 billion. These costs are preventable if and when people living with diabetes can properly manage their conditions through access to the medications they need.

Bill C-64 represents an important step forward to ensure that every Canadian has access to the affordable, quality medications they need. It will provide Canadians with free, single-payer contraceptive and diabetes medication coverage. It also sets out a framework to build and expand this first step into the national, universal, public, single-payer pharmacare system that the Hoskins report and countless other national reports and studies have repeatedly recommended.

Following Royal Assent of this bill, several key steps will take place. First and immediately, the Minister of Health and his department will move to conclude bilateral agreements with provinces and territories regarding single-payer, first-dollar contraceptive and diabetes coverage.

British Columbia has already entered into a memorandum of understanding with the federal government, indicating its intention to enter such an agreement. Since B.C. currently provides universal coverage of contraceptive medicines, savings for the province will be reinvested into essential free, single-payer coverage of hormone replacement therapies for post-menopausal women.

In addition, the Minister of Health will establish a committee of experts within 30 days. The committee will begin its work on options for the operation and financing of national, universal, single-payer, first-dollar pharmacare. And, equally important, within one year of coming into force of the act, Canada’s Drug Agency will prepare a list of essential prescription drugs and related products to inform the development of a national formulary and provide advice on a national bulk purchasing strategy.

Testifying before the Senate Social Affairs Committee, the Minister of Health confirmed the importance of ensuring that expert committee members are free of commercial interests in the pharmaceutical sector, echoing a previous commitment that decision-making processes of Canada’s Drug Agency must likewise be independent.

This emphasis aligns with the recommendations of the Hoskins report that Canada’s Drug Agency must be free of conflicts of interest so that its work is rigorous, equitable, evidence-based and firmly aligned not with commercial interests, but with the best interests of Canadians.

Ensuring independence and freedom of conflict of interest in decision making will require vigilance, including in standing up to the pressure to follow the lead of the United States and implement a fill-the-gaps, mixed public-private system. We cannot regress to a patchwork of literally thousands of independent private and public drug plans and the administrative cost and program complexity this entails, both for patients and prescribers. We cannot continue to accept multi-payer systems that fragment Canada’s purchasing power when negotiating prices and supply guarantees with multinational pharmaceutical companies. We cannot, in good conscience, keep asking individual households and employers to bear most of the program costs on their own.

As we look to the next phase of pharmacare, we are importantly reminded of the reality that the initiatives outlined in Bill C-64, as well as those that are already under way, will all continue and be evaluated for their lessons learned with respect to the advancement of national universal pharmacare in Canada. This includes improving access to affordable prescription medications in Prince Edward Island, efforts under the National Strategy for Drugs for Rare Diseases and work by Canada’s Drug Agency.

I truly look forward to the positive impact that this legislation will have on Canadians. At the same time, I am aware that work on Bill C-64 is far from over. This legislation marks the beginning of a path that we must walk together to blaze the national, universal, public, single-payer pharmacare system trail that Canadians want and to ensure the universal access to medications they correctly claim as a human right.

I share Canadians’ commitment to national pharmacare as a logical extension of our national medicare system and a vital step toward ensuring that no one is denied the health care they need because they cannot pay. Through the coming months and years of implementation of this legislation, I trust we will continue to work together, with and for all Canadians, toward pharmacare for all.

I am under no illusion that this will be a quick or easy process. Bill C-64 requires step-by-step work in concert with Indigenous peoples, provinces, territories, community stakeholders, experts and those with lived experience. I reflect upon that often-quoted saying that if you want to go fast, go alone; but if you want to go far, go together.

This will be a long-term and iterative process, but it is one that I believe Canadians are committed to and one we are making meaningful progress toward today. The first step is to heed the calls repeated at the Senate Social Affairs Committee on behalf of Canadians awaiting meaningful access to medicines, and that is to pass this legislation without delay.

Meegwetch. Thank you.

Thank you. That’s an excellent question, and, of course, this is also within provincial jurisdiction. It will largely be the responsibility of provinces to encourage employers to renegotiate, whether it’s lower co-pays or lower rates to accommodate these issues. I think what you’re raising is a very important question. It’s one that certainly the government is alive to, and I would hope the provincial and territorial governments are also alive to it and have already started those discussions. The last thing anybody wants through this legislation is to limit people’s access or to not defray more of the costs.

It will be up to provinces to negotiate and sign onto this, and certainly those cost savings will hopefully be passed on to Canadians in their regions.

Thank you. There’s speculation as to what might happen there. The PBO costed based on an understanding that this iterative process was actually a multi-payer system instead of the single payer that it is designed to be. There may be some additional costs. There would also be the expectation that the agreements with the federal government and the provinces would actually address these very issues.

In fact, I would suggest — and other colleagues in this chamber have far more experience than me — that this will be the type of negotiation that employers will be having with the government. Certainly, unions have been having that discussion, hence the reason there is such huge support for this initiative across unions and across the labour movement in this country.

Well, in my discussions with experts in other parts of the world, what it has generally meant is employers have been able to either reduce costs or extend coverage in other areas that weren’t otherwise negotiated. That stands as a positive step in most cases, as well as a human right to have access to this kind of coverage. I suspect, in the worst-case scenario, there may be legal challenges if employers try to do that.