Honourable senators, I will quickly summarize and then proceed with the remainder of my speech.

As long as financial coverage across Canada remains inconsistent, people must rely on networks of advocacy organizations, such as Action Canada, for trustworthy evidence-based information on the available forms of contraception in their respective provinces and territories and be empowered to make the choices that are right for their health.

This bill is essential because Canada’s patchwork of access to contraception is unsustainable. For example, all provinces and territories have expanded prescribing authority to a wider network of health professionals, including pharmacists, midwives and registered nurses, but only 46% provide financial coverage for all their population. A cross-sectoral, interdisciplinary research project led by the European Parliamentary Forum for Sexual & Reproductive Rights with Action Canada and University of British Columbia, or UBC, researchers produced the Global Contraception Policy Atlas to monitor countries on contraceptive policy, education and access.

Per this comparative atlas, British Columbia ranks highest in Canada while Newfoundland and Labrador ranks lowest, close to my own province, Manitoba, in tenth place. Bill C-64 intends that Canadians will have access to a comprehensive suite of contraceptive drugs and devices, meaning that some 9 million Canadians of reproductive age will gain reproductive autonomy, bringing down the cost barrier that is unevenly borne by women and gender-diverse Canadians.

According to UBC researchers, contraception medications can cost more than $19,000 over the course of a woman’s life. The Canadian Patented Medicine Prices Review Board, or PMPRB, which is mandated to track and monitor that drug prices are not excessive, has stated that Canada currently has the third-highest prices globally and that we also spend more per capita on drugs than any OECD country other than the U.S.

Pharmacare opponents concerned about a national bulk purchasing strategy often try to downplay this excessive financial burden by citing that Canadian drug prices are simply the median of OECD countries. This is misinformation. Yes, Canada’s prices are at the median of the seven OECD countries that the PMPRB uses as comparisons, but these countries represent collectively the highest drug prices in the world.

While we are examining cost, allow me to be frank: The costs in Bill C-64 are going to be less than the costs of doing nothing. Studies show us over and over that free contraception programs save by reducing costs associated with birthing and abortions, in addition to the high rates of care needed for postpartum mothers and babies.

Opponents of Bill C-64 suggest that universal coverage is unnecessary, claiming that only 3% of Canadians are ineligible for insurance that would cover the cost of prescription medication. This argument comes from an industry-funded report based on data provided by the principal insurance industry lobby in this country that defined this as technically eligible private or public drug coverage with high deductibles or costly premiums that many cannot afford.

The Conference Board of Canada and other witnesses before the Social Affairs Committee noted that the lobby’s 3% figure does not account for the reality of exorbitant drug pricing that makes procuring medications a financial impossibility for upward of 30% of Canadian households, regardless of whether they are technically eligible for coverage.

The UBC Contraception and Abortion Research Team found that 70% face access barriers to contraception. Genuine access to contraception is more than simply a health issue — more than a women’s issue. This is about reproductive injustice. From a generation much younger than mine, Meghan Doherty, Co‑Director of Global Policy and Advocacy at Action Canada for Sexual health and Rights — the civil society partner of the Canadian Association of Parliamentarians on Population and Development — gave me this commentary to share with you today:

When we think about the root causes of the injustice related to gender and sexuality and reproduction, we’re really looking at some of the same root causes, which can be understood in terms of patriarchal gender norms entrenched in all parts of our social, economic and cultural lives and manifest in laws, policies and budgets. At their hearts, what they are designated to do is to create a situation where gender is used to subjugate, exclude and marginalize particular people based on their gender and really elevate and prioritize men, all of the norms associated with masculinity. The idea that all sexuality should be about reproduction, and that translates into real human rights violations, blocking access to sexual and reproductive care that many people need.

Colleagues, the health, economic, social and equity impact of free contraception cannot be overstated and benefits everyone. In keeping with Senator Cardozo’s helpful historical notes to this debate, I wish to close with a quote from Canada’s own esteemed Stephen Lewis, who served in many high-level, multilateral posts, including as our ambassador to the UN and as a member of the World Health Organization Commission on the Social Determinants of Health. It was 30 years ago when he said:

A woman’s economic well-being, her own health and her children’s, her aspirations, her hopes for family betterment, the level of her education, the realistic options for employment or child care, the wholesomeness of available shelter, food and water, all these and many more . . . factors will enter into her reproductive choices. . . . A woman’s reproductive choice lies at the core of a thousand influences and pressures. She is palpably the one best equipped to make flexible decisions.

Honourable colleagues, let’s vote now to support universal pharmacare and to support this bill as a pathway to achieving that goal for all Canadians and a stronger Canada.

Thank you. Meegwetch.

Honourable senators, I also rise to speak on this very important piece of legislation. I was struggling over the last number of days, trying to figure out what I would say in regard to this debate.

In the end, I didn’t read another statistic or data published many times before. I decided to tell my own story — how I got here and why.

In 2017, in my previous life as President of the Canadian Labour Congress, or CLC, the convention passed a resolution saying the CLC should conduct a campaign to get our country to adopt national pharmacare. As in any process after you pass a resolution, we went back to the organization headquarters. I assumed that it was not so simple. I was not convinced we had a problem, and how was I going to know if we had a problem unless we talked to our members?

So I embarked across the country on a 30-city tour. I went to large cities and small cities. I thought, of course, being in the labour movement, we were very good at representing our members, bargaining for them and ensuring they have proper coverage, so I assumed I certainly was not going to hear from our members that they had a problem. What I heard shocked me because the stories they were telling me were not about whether they had coverage. If you read the collective agreement, they said, “Yes, we do have coverage.” A single mother told me that under her collective agreement, she was supposed to be able to access the medication, but before she could do so, she had to pay a deductible of $700. She said that if she had had $700, she would have bought the medication. She asked, “How do I explain this to my child?” I didn’t have an answer.

I know her union, in their best efforts, did not put a deductible in the collective agreement because they were stupid. It was part of the bargaining process to at least establish a floor to access benefits. Of course, it was a deterrent; the majority of members did not have high-paying jobs and could not access the medication.

I heard from individuals who had coverage under their current job and were leaving to go to another job. During that of 60 or 90 days in which they completed their probation period, they received no medication. So they wondered, long before they left their initial job, how they could stretch the medication they had to cover that period.

Of course, not taking the medication they were required to take in proper doses destroyed their health. Their health is now worse than before. At the end of the day, they are asking, “Why is this happening?”

When I finished the 30-city tour, I returned to my office. On many occasions, I cried at the events we were holding. I could not believe, in a country as rich as ours, this is how we treat so many of our citizens.

I say this to you because I’m speaking as somebody who, from the age of 18 and up until today, has always had full access to medication whenever I needed it because I had good collective agreements and coverage. In all these years, I have never had to take a medication for my health. I’m fortunate. But my good fortune should not be my guide as to what we do.

Now, here we are, a country that is 157 years old. I said a long time ago that nation building is never easy, and that’s what we are involved here, my friends: nation building for all our country’s citizens. Those who are wealthy enough will never need to be covered by a plan, and those who are poor enough should never have to worry, should they get sick, whether they can access their medication.

I’m fully aware that as I travel the country, the provinces and territories in this federation, things are not always the same. If you live in Quebec, they have different rules. Is it perfect there? By no stretch of the imagination. If you live in British Columbia, it is different. Provincial programs across the country are all different.

But here is the sad reality: If you get sick and go to a hospital in this country, they will give you every drug necessary to get you better — until they kick your ass out the door. Then you are on your own because you no longer have access to that medication unless you have coverage or the wealth to purchase it. How is that possible? When you are sick, they will look after you, but the minute they kick you out the hospital door, at the end of the day, you have no access to medication. This is not right, my friends.

I know we are having a debate. I want to start by thanking the Standing Senate Committee on Social Affairs, Science and Technology for the work they have done and all the witnesses who came to testify, both those in support of and those who criticize the bill. This is part of what democracy is about.

I want to thank Senator Pate for her diligent, hard work in sponsoring this bill. Colleagues, I know we will not all be of the same mind today as we get to the end and vote on this bill.

However, I have reflected on this in many ways. I had a good friend who had a heart attack in Windsor. I went to visit him in hospital. As he was lying in his hospital bed, he was told his company had just declared bankruptcy. He is fifty something years of age. Two things happened when the company went bankrupt: His pension was not fully funded, and he didn’t have super-priority for pensions in bankruptcy, so he was not going to get the pension he was promised. He was lying in a hospital bed from a heart attack. He was also told, while lying in that bed, that 30 days from that day, his coverage for medication would cease. He looked at me and asked what he should do, how he should provide for his family and how he would take care of himself when he left that hospital. With my good friend, I was honest; I told him I didn’t know and did not have the answers.

I was fortunate to be here. Thanks to my friend Senator Plett and his colleagues, we passed a bill and changed the law on bankruptcy so that, should a company go bankrupt, workers will get super-priority to ensure their pensions will be fully funded in the future.

However, we didn’t fix the other part of the problem: What about his medication? His medication came from his contractual agreement. When a company goes bankrupt, there is no longer a contractual agreement.

I will conclude my comments. I watched Dr. Hoskins when he made his report and travelled the country with his team. I thought they put together a very good report for our nation. Our provinces and territories are trying with their best effort to figure out how to help their citizens. However, the reality is we have a patchwork in this great nation of ours. We must recognize we can do better.

If you live in New Zealand, you can buy Lipitor, a drug we produce in this country, cheaper than you can purchase it in Canada. How is that possible? I think we are in the process of trying to build a better system using bulk purchases to buy some of the best medication we can.

But as I conclude my remarks, I want to reflect on two important things. My mom of 100 years this May had never had drug coverage. She was never rich enough and never worked for an employer who would provide her with drug coverage. She turned 100. Next year she will be 101. Despite all that, she has done all right.

This is about how we make change. I hope in the next 100 years, my young, 16-year-old daughter, who will soon become an adult, will not have to wait 100 years like her grandmother did to be sure she is going to have drug coverage.

This bill provides the foundation of how we can build a better system working with the provinces and territories across the country while at the same time working with private employers regarding their responsibility. Much has been said about private employers. Are they going to get rid of the coverage because of this? I have represented workers my whole life. Yes, some might try to do that. However, as you know, a contractual agreement does not give an employer the right to take something away from workers unless the workers agree to it. For all the hype we have heard about workers losing their coverage, the labour movement has been at the forefront, arguing for this bill to come into place and supporting the expansion. In provinces where they are able to articulate and support the government, the government has said, “You need to expand your coverage.”

I know we can do better, colleagues, but I think we need to reflect upon this. Just because you have a privilege, it doesn’t mean you don’t think about your fellow citizens who don’t have that privilege. I hope the privilege that I have had in my life becomes a right for every citizen in this country. I think this bill is the foundation to get there.

Thank you.

Honourable senators, I rise today to put on record concerns regarding the impacts of this pharmacare program on the Non-Insured Health Benefits, or NIHB, program currently available to First Nations and Inuit beneficiaries.

There were concerns brought up by the Onion Lake Cree Nation during the Standing Senate Committee on Social Affairs, Science and Technology’s deliberations on the national pharmacare program. Although Onion Lake officials were unable to appear as witnesses at the committee despite their request, they still submitted a briefing document for members to consider. In this submission, they requested that Onion Lake Cree Nation not be included under this legislation because of its eschewing of the spirit and intent of the medicine chest clause in Treaty 6.

In response to these concerns, I sent correspondence to Minister Holland on October 8, which was marked as time-sensitive given the very truncated third reading timeline we are facing for this bill. This letter reinforced the concerns of Onion Lake Cree Nation and sought to clarify how Bill C-64 may impact the existing pharmacare program that First Nations and Inuit peoples have access to and what the government would do to address any such potential impacts that may arise. I also asked how the provisions of this bill might negatively impact First Nations’ and Inuit peoples’ inherent and treaty rights more generally. While I had received an informal response from the minister’s office yesterday that included an indication that a formal reply would be issued by this morning, I have not received that reply from the minister at the present time.

Colleagues, Indigenous Services Canada’s NIHB program is a national program that provides First Nations and Inuit peoples with coverage for a range of medically necessary health benefits. Those benefits are not otherwise covered through private, provincial or territorial health insurance plans or via social programs. Will this pharmacare plan be considered an insurance plan or a social program? That remains unclear, which is concerning.

Honourable senators, in my role as the Regional Dental Officer for the Manitoba region from 1996 to 2000, I worked with the pharmacy and dental databases to oversee the dental program. As such, I am familiar with how fluid these changes to benefits and payments for these benefits are for First Nations and Inuit peoples and how concerning that was then. This concern remains present today. I remain unable to see what the pharmacare program under Bill C-64 will look like, what the fees will be and how the NIHB and the pharmacare programs will interact.

Will First Nations NIHB program benefits be included or considered in this pharmacare program? How will these two different programs be delivered, and how do they differ? What are the negotiated fees, and who was involved in those negotiations?

References to or the use of “dispensing fee,” “usual and customary dispensing fee,” or any variations thereof are subject to reimbursement up to the regional maximum of the program. Pharmacy providers in Quebec should refer to the agreement between Indigenous Services Canada and their representatives. Are these dispensing costs considered in the program, and, if not, who will absorb the cost?

It is the pharmacist’s responsibility to verify benefit eligibility for the client at the time of dispensing to ensure that no limitations under the program will be exceeded and to ensure compliance with benefit criteria and policies.

We have different programs in different provinces: you have pharmacare, you have non-insured benefits and you have social programs. It will be a difficult role for the pharmacist. I know this because the same thing happened with the dental program. Is that how this program is anticipated to work?

Clients of the NIHB program do not pay deductibles or copayments if the negotiated fees are too low. Every year they are too low, and a lot of providers opt not to provide the program. Is that also a function of this program?

Decisions on drug and pharmacy benefits are based on the judgment of recognized health professionals, consistent with the best practices of health services delivery and evidence-based standards of care. Will that be the same for this program?

You will remember it was Revenue Canada that initially ran the dental program, which was a major concern.

What are the benefits in the drug benefit list? As you know, there are a lot of medications that are used to treat diabetes. Will there be exceptions, with prior approval, under special circumstances? What would that process entail, and how long would it take?

When I did benefit exceptions and I had my patients, I would go in at the beginning of the week. By the end of the week, as I was leaving, I didn’t get that benefit exception. There was no response.

There may be special circumstances when the prescription is for a recognized clinical indication and dose that is supported by published evidence or authoritative opinion and there is significant evidence that the requested product is superior to products already listed in program benefits. When new drugs would become available for diabetes and they were not put on the formulary, people had to ask for benefit exceptions. It could also happen when a client has experienced an adverse reaction with a best-price alternative product and a higher-cost alternative is requested by the prescriber.

Patients who are diabetic and qualify under pharmacare may be at the end of life. What does that formulary look like? Will they require supplemental benefits? Will these be included on the drug benefit list?

Honourable senators, when the NIHB Drug Exception Centre is informed that a client requires end-of-life care, an end-of-life care formulary application form is generated and faxed to the prescriber. For example, this happens to patients on dialysis. In First Nations, there are many people on dialysis.

People who have not taken medications for their Type 2 diabetes because they couldn’t afford them can already have various health problems such as heart disease, kidney disease and stroke. It is important to ask what diabetes medications this program covers.

Once this end-of-life care formulary application form is completed and submitted, the client will be eligible — and this under non-insured benefits — for all products on the end-of-life care formulary if the following criteria are met: The client is not receiving care in a provincially covered hospital or long-term care facility, and the client has been diagnosed with a terminal illness or disease related to their diabetes that is expected to be the primary cause of death within six months or less.

Under NIHB, once approved, the client will be eligible for all products on the end-of-life formulary for six months, without the need for further prior approval. If coverage is required beyond the initial six months, an additional six months may be granted upon receipt of a new end-of-life care formulary application form request.

Colleagues, who absorbs the cost when there is a refusal to fill the dispensing fee — for every medication we have, there is a dispensing fee, and at this time, I think it’s about $7 per prescription — especially in the provinces of B.C., Saskatchewan and Manitoba when a drug has been deemed not to be in the best interest of the client?

There are many other considerations that remain unclear to me with this proposed program, including around the reversals for prescribed products not picked up by the client — in the database on that, there were patients who did not pick up their prescriptions. Under the NIHB program, when a client has not picked up a prescription within 30 days, the original paid claim must be reversed and resubmitted for payment of only the dispensing fee. The submission of a claim for a dispensing fee where the client has not picked up a prescribed product which can be reinserted to inventory only applies to products with a dispensing fee dollar value. This is not a problem when reinsertion is not possible.

What is this process under Bill C-64’s program?

There are also questions around the coordination of benefits under this new program. You can see what Non-Insured Health Benefits provide for First Nations and why it is of concern to them that these questions have not been addressed. People eligible for benefits under NIHB are required to access other public or private health plans, or provincial or territorial programs for which they are eligible, before accessing NIHB benefits.

Pharmacy providers must confirm with each client whether other coverage exists, and a claim must be submitted to the other party first for processing. Once this party processes the claim, the provider may then submit any remaining balance to NIHB.

In this instance, who will be the payer of last resort in these programs? When you look at our plan under Canada Life, they also say they are the payer of last resort. We often used to have this problem. Who is going to pay, and who will get caught in the crosshairs?

Under the Ontario Drug Benefit program, claims cannot be coordinated. They may access drug coverage from either NIHB or, if they are eligible, through the OHIP+ program.

When an eligible client indicates that they no longer have benefits coverage through another private or public health care plan or social program, the provider or client is asked to communicate this to the NIHB program so that the client’s file can be updated.

How will this pharmacy plan affect First Nations and other clients? Are First Nations and Inuit peoples effectively exempt or excluded from this program due to their superior coverage through the NIHB program? Conversely, under this plan, how will the providers verify that the individual is eligible for benefits under Indigenous Services Canada’s NIHB program and identify any other benefits coverage available to the client, if applicable?

Honourable senators, as a result of the different programs that overlap, and possibly conflict, the providers will have to be well versed as to who is eligible under what programs. As a result, there must be a robust appeal process in place. What will this appeal process entail? Will it be online? If so, this poses accessibility issues for multiple vulnerable populations.

A final concern is whether this program’s prevalence will facilitate a delisting of benefits for First Nations who, again, have access to greater coverage than offered by this proposed program.

Colleagues, although I understand the benefit this program will yield, I hope it is clear from my remarks that many fundamental questions remain unanswered for me as they pertain to the bill before us, both with regard to the program itself as well as how this program will interact — or interfere — with the prevailing NIHB program.

Kinanâskomitinawow. Thank you.

Senator Osler wishes to ask a question, but we ran out of time. Senator McCallum, are you asking for more time?

No, time has been denied. On debate.

Honourable senators, it seems I stand up at a point in time when the honourable senator across from me just denied the opportunity for someone to have additional time before they asked for additional time. The rules are hard-and-fast by some people’s thinking, though for some of us, circumstances give rise to consideration at any given time.

Honourable senators, I thought long and hard about whether I would enter this debate, and I intend to do so for just a few minutes. I am so happy and proud to be here today, when, I believe, if all goes as has been agreed to, we will be taking a vote on this important bill and there will be a historic moment in the continuation of the journey for the universality of health care supports and benefits, as well as the building of a healthier Canadian population.

My father was a lifelong Progressive Conservative voter. He, along with my mother, instilled in me a set of values at a young age, to question, understand and make my own determinations. He planted seeds. I look back and — long story short — he travelled on the road from Monday to Friday. When he came home on the weekends, our dinner conversations would often focus on current events — things happening around the world, but also in Canada. He also instilled in me a practice of watching the news on television with him on Friday, Saturday and Sunday nights.

At a very early age, when I didn’t know what politics was or who politicians were, whenever Tommy Douglas came onto the screen, either being reported on or interviewed, my father would say, “You know, Frances Louise —” my mom was Frances, so I was Frances Louise “— if that man were the leader of any other political party, he would be Prime Minister of this country.” Well, thanks, Dad. I didn’t know why that was important or what it meant.

But my parents instilled values in me that, interestingly and surprisingly enough, guided my life. As all of you know, when I became active in politics, I became active as a devotee of the wonderful, recognized-as-the-greatest-Canadian Tommy Douglas and, or course, the New Democratic Party. That’s where I began my life in politics as an independent.

But through those years, the journey of medicare, dental care and pharmacare has been a driving force. I had the opportunity and honour to serve as Minister of Health in Ontario at a time of recession, large deficits and a need to get budgets under control. The biggest booming ministerial expenditures in budgets were those of the Ministry of Health, largely fuelled by increasing drug costs. I had very interesting relationships with both the brand-name pharmaceutical industry and the generic pharmaceutical industry, in particular the late Barry Sherman. When I was at the United Way, I would go and make appeals to him, and he would sit and talk to me about health care. He was always generous. That’s where his focus was. This issue of how we move in difficult, constrained fiscal times to ensure a greater coverage and a greater access to life-preserving, health-promoting medicines, procedures and services remains a preoccupation of mine.

In the Province of Ontario — and not dissimilarly, in the Province of Quebec — the population bases were so large that drug formularies — how they operate and constraining costs, yet increasing access — was a preoccupation of ministers of health, of course, but of entire cabinets. When introducing the programs I had the opportunity to work on, in a time of a deficit, to try to ensure what we called in Ontario “catastrophic drug coverage” — those medicines that were beyond what health plans, if you had access to a health plan, would cover, which were beyond the capability of the vast majority of Ontarians. It was a critical part of our thinking and a big cost. At the same time, it was completely focused on trying to move resources within a constrained budget from illness treatment to illness prevention, to health and well-being promotion and to the social determinants of health writ large across government. These all tie together, and come to a moment now with this bill that I see as an historic next step.

I thank Senator Cardozo for reminding us about how long it has taken, and the journey is not over with respect to ensuring medicare. The patchwork of access to services and supports, in particular, philosophies, principles and budgetary assignments against those for our medicare program continues to evolve. It’s only beginning on dental care, and it’s just taking its first tentative steps with respect to pharmacare.

I thank those senators. Not all of us agree on this, but I think those senators whom I have heard largely — in terms of the speeches that have been delivered — really recognize that this is a base and has said there are all sorts of shortcomings. I think that Senator McCallum’s recitation of the kinds of questions that need to be answered is instructive. Print it off, keep it and as this evolves, keep coming back to those questions. Those are important questions.

I think the senators who have said in many speeches that this doesn’t go far enough, this is not universal, this is not, et cetera, but have said that this is important and I will support this bill. I read the room, in majority, that when we take the vote today — I can’t predict — I believe this bill will be passed. I will be here for the vote and for Royal Assent. It’s important.

I want to say to the witnesses who came, and in particular to the group of academics who, at one point as this has unfolded in the Senate review, issued a statement that there are so many problems with this and so many unanswered questions that this is worse than doing nothing at all. It will bake in problems that we will have to have legislation to fix, we don’t have adequate definitions, on and on — this is worse than doing nothing at all. I understand the concerns that brought them to profess that point of view. I think maybe they have moved from that, but let me say that I understand.

I agree with the concerns at the base of it. I disagree profoundly with the conclusion that they arrived at. This is not in any way to be disrespectful. This is to say that we all have different jobs in looking at legislation and policy that comes forward. We all have different expertise to provide advice on. I think that the perceptions and the positions that were taken by that group lack the understanding of the political process of building consensus and moving forward on major public policy interventions in this country. It lacks the understanding of federal-provincial relations. It lacks the understanding of province to province and the interprovincial issues with the patchwork that is there. It lacks the understanding of the fiscal frameworks that we have to take our decisions in. It ignores the urgency of other issues that are also on the table that we are dealing with at the same time. And it doesn’t get politics.

I don’t say that as a criticism levelled at those individuals. I say that as a reflection of my perception of what they said and my perception of the reality that I’ve worked in as a former health minister, as a predecessor minister with a couple in between before Dr. Eric Hoskins became Minister of Health in Ontario and as a person who followed his task force and their recommendations — I understand how this has evolved and unfolded.

I understand that this is not a toe in the water. This is bigger than that. This is jumping off the end of the dock into cold water and not knowing exactly what you will find down there, she says where she lives with the muskies down there below the docks. All of the questions that are being raised that need to be worked through and to be answered are important.

Why the focus on just the two? Senator McPhedran, I’m glad to have been here to listen to your presentation around issues of reproductive and sexual health and all of the connections. As you know, I’m a long-time friend and devotee of Stephen Lewis as well. I love to hear his quotes. I appreciate that.

I’ve also done a lot of work with respect to access to diabetes drugs. I know the extraordinary financial burden with a disease that can be controlled, mitigated and give the room and space for people to take life decisions with guidance, support and the right medication to turn around those situations and be able to continue to live a healthy life.

For me, this is a foundation stone of moving to the concept of a pan-Canadian approach. There is lots to work out. This is not universality, but it is the first step towards universality. It is an incredibly important first step.

Colleagues, as I said, I read the room that we will come together and, in a majority, we will support this. I believe the thoughtful presentation of “we must do this,” but we must also address these other issues that remain outstanding that will be guidance for policy-makers about the intersection between policy and politics in the future. I welcome watching that.

I appreciate the opportunity to have addressed this. I appreciate the work that Senator Pate has put in, the leadership that she has provided in this chamber and in working with people from all points of view and various communities to bring this forward. I appreciate her own acceptance of this is as a step and a foundational step. This is from a woman who is — like my other senator friend over there — a warrior to move as far as possible when we know what the right answer is. I admire that. I’m not making too big of a deal of it here, but I truly do because coming to terms with this as people who are really anxious to get the right thing done, I understand. I am an idealist. I’ve also learned to be a pragmatist. This is the amazing first step to realize the ideal, and it is a pragmatic first step that will allow us to build into the future and to get there.

If you weren’t going to vote in favour, I implore you to reconsider, but I hope that we see this pass today and Royal Assent given, and that we all get down to work on the next steps that will be required. Thank you very much.

Honourable senators, I rise today as opposition critic to speak at third reading to Bill C-64, An Act respecting pharmacare.

First, I would like to thank our chair, the sponsor, Senator Pate and committee colleagues for all of their efforts to listen and respond to the testimony of experts, stakeholders and those with lived experience on a challenging piece of legislation. Today, I will seek to explore what “universal” might mean given that the term has many different definitions.

In the context of pharmacare, there are well-known international examples. I will then revisit some key questions that I raised in my second-reading speech, questions I had hoped committee hearings might shed more light on. Finally, I will share some issues raised by provincial and territorial governments with regard to jurisdictional respect.

To begin, honourable senators, let us assess the assertion that Canada is the only country in the world with universal health care that does not provide universal coverage for prescription drugs. When parliamentarians repeat this remark, we should be explicit in identifying what we mean by the term “universal.”

In the Canadian health care context, we often speak of universal coverage as if it must mean single-payer coverage; however, A Prescription for Canada: Achieving Pharmacare for All, the 2019 Final Report of the Advisory Council on the Implementation of National Pharmacare — sometimes referred to as the Hoskins report — notes that a statutory multi-payer insurance approach is used in a number of countries of the Organisation for Economic Co-operation and Development, or OECD, including France, Germany and the Netherlands, to “. . . provide universal health insurance (including drug coverage) to their residents.”

Annex 5 of the report summarizes key characteristics of the pharmacare systems in these and other comparator countries. This annex makes it clear that universal pharmacare coverage does not mean that the state is exclusively responsible for prescription drug costs, nor does it mean that the plan must be publicly administered.

The Australian system of universal, comprehensive public pharmacare coverage has copayments equal to the lesser of $37 or the full cost of the drug. Copayments are reduced to $6 once a household has paid $1,425 in copayments during the calendar year. About half of adults have voluntary complementary private insurance.

France has universal, comprehensive statutory insurance coverage. The plan pays for as little as 15% and as much as 100% of prescription costs, depending on the medicine’s clinical benefit. More than 90% of residents have voluntary complementary private insurance.

The German system of universal, comprehensive statutory insurance requires copayments of approximately $7 to $15 and allows residents earning over $90,000 a year to opt to purchase substitutive private health insurance.

The Dutch system of universal statutory insurance coverage requires an annual deductible of $584, and more than 80% of residents have voluntary complementary private insurance.

Universal coverage and single-payer coverage are not synonymous. Many of our peer countries have statutory multi-payer pharmacare systems that have much more in common with the Quebec model than with the model proposed in Bill C-64. As a reminder here, I will quote the Hoskins report directly:

Quebec is the only Canadian jurisdiction that has achieved universal drug coverage and it did so by making drug insurance mandatory for all residents. Employers that provide health benefits to their employees are required to provide prescription drug coverage that meets or exceeds the level of coverage provided by the province’s public drug plan. Residents who are not eligible for private insurance through their employer or occupation are required to enrol in, and pay premiums for, the provincial drug plan (some vulnerable groups, such as low-income seniors, are exempted from paying premiums).

Adopting the Quebec model would meet the objective of providing Canadians with universal pharmacare coverage, but in Bill C-64, the government instead proposes a much more expensive plan that will decrease choice for Canadians.

Further, Bill C-64 appears designed to confuse Canadians. Neither the bill’s summary nor its purpose makes mention of prescription drugs intended for contraception or the treatment of diabetes. It speaks of “national universal pharmacare.”

As I noted at second reading, Bill C-64 seems to propose two policies: a conceptual, so-called universal program for the government to work toward and, second, the structure and processes for the implementation of a fill-in-the-gaps coverage for “. . . specific prescription drugs and related products intended for contraception or the treatment of diabetes.”

Why do I say, “fill-in-the-gaps”? This might have been the intent because clause 6(1) states clearly that the minister must “. . . make payments to the province or territory . . . to increase any existing public pharmacare coverage . . . .”

In fact, the Prince Edward Island demonstration project that preceded this bill was a fill-in-the-gaps model. Are you confused yet? Canadians deserve legislation that is transparent. Bill C-64 is not.

Colleagues, I will provide an overview of the main questions I raised at second reading of Bill C-64 and how these were addressed — or not — at committee.

At second reading, I asked whether national, universal, single-payer pharmacare may have a negative impact on pharmacists’ practice. At committee, Dr. Shelita Dattani from the Neighbourhood Pharmacy Association of Canada recalled the challenges of implementing OHIP+ in Ontario. She said:

. . . in 2018, the OHIP+ program in Ontario sought to provide comprehensive medication coverage to Ontarians under the age of 25 whether they had existing coverage or not, based on the Ontario provincial drug formulary. This was well intentioned to ensure no youth was left behind, but in reality, the government paid millions more than needed for medications Ontarians were already accessing. Many of these young adults faced a disruption when their coverage changed or the medication . . . was not now covered by the provincial formulary. . . .

Dr. Danielle Paes, the Chief Pharmacist Officer at the Canadian Pharmacists Association, also shared her perspective as a pharmacist who is on the front line:

I think a lot of what pharmacists do is behind the scenes. We are on the phone with insurance plans. . . . It is not just a list. It is a matter of making sure that everything aligns so that the actual drug gets into the hands of the patients. . . .

On the potential financial implications of Bill C-64, Dr. Benoit Morin of the Association québécoise des pharmaciens propriétaires warned that some Quebec pharmacies will not survive if they can only charge one dispensing fee which has been set by the province or territory. Private plans pay higher dispensing fees; therefore, pharmacies’ finances depend upon a combination of fees from prescriptions filled on the public plan and prescriptions filled on the private plans. He said:

It is precisely this flexibility that allows Quebec pharmacies to grow, to be present in all regions and to offer a multitude of services to patients. Without this flexibility, the financial health of the pharmacy network would be undermined with even greater repercussions in remote regions.

Dr. Dattani from the Neighbourhood Pharmacy Association underscored this point when she said, “. . . an unintended consequence of single-payer Pharmacare could very well be a reduction in pharmacy services and medication access.”

At second reading, I asked, “Can we, in our current health care ecosystem, afford to jeopardize the success of our pharmacies and pharmacists?” It seems that the federal government is poised to do so.

At second reading, I voiced the concern that national, universal, single-payer pharmacare could erode access to drugs and exacerbate drug shortages. At the Standing Senate Committee on Social Affairs, Science and Technology, Ms. Joelle Walker of the Canadian Pharmacists Association addressed this concern:

Pharmacists spend about 20% of their time managing drug shortages. . . . The concept that if you bulk buy a lot of drugs, you save money is perhaps accurate in the pure sense, but it also has a lot of consequences. We’re most vulnerable in Canada when we only have one particular medication for something. . . .

Ms. Walker also noted that there is a common misconception that governments buy drugs. She said:

Pharmacies buy drugs, and then they are reimbursed by governments for those drugs. Bulk purchasing is . . . predicated on a concept, which is that you have to buy one particular drug in bulk, and that’s what makes us vulnerable to drug shortages. . . .

Angelique Berg, President and CEO of the Canadian Association for Pharmacy Distribution Management, told the Social Affairs, Science and Technology Committee that an unintended consequence of Bill C-64 is that it could exacerbate drug shortages and result in contracted availability of drugs on pharmacy shelves. She cautioned that a restrictive national formulary and bulk purchasing agreement could disrupt Canada’s drug supply. The potential for disruption:

. . . can already be seen with the proposed national pharmacare list of diabetes drugs, which only includes half of the drugs on the market today. Affected Canadians would be forced to switch from their current therapy to something on the list, which has a domino effect on the supply chain. As distributors’ buffer stock is depleted and manufacturers of drugs not listed on the list leave the market, over time, the drug supply will be more vulnerable to shortages.

Jim Keon, the President of the Canadian Generic Pharmaceutical Association, noted that the term “bulk purchasing” is not defined in Bill C-64, and it is therefore unclear what it will mean. He reminded the committee that Canadian governments already combine their purchasing power to negotiate internationally competitive drug prices for Canadians through the pan-Canadian Pharmaceutical Alliance, or pCPA. He said:

It is critical that the pharmacare regime respects the existing pharmaceutical pricing infrastructure to ensure stability of the Canadian drug supply.

Any further pressure on generic drug pricing will lead to additional drug shortages, the number of which are already unfortunately high.

. . . limiting the number of suppliers for a given medicine . . . increases the risk of drug shortages. If the chosen supplier or suppliers have production or other issues, there could be few, if any, alternatives to meet patient needs.

At second reading, I asked whether costs for a national, universal, single-payer pharmacare program could far exceed current estimates. The Parliamentary Budget Officer, or PBO, estimated that the first phase of national universal pharmacare would increase federal program spending by $1.9 billion over five years.

Budget 2024, meanwhile, committed $1.5 billion over five years to Health Canada to support the launch of a national pharmacare plan. Therefore, the committee knew, before hearings even started, that pharmacare was underfunded by at least $400 million. But the PBO’s estimate assumed that any medications that are currently covered by provincial and territorial governments, as well as private insurance providers, would remain covered on the same terms. In other words, he presumed a fill-in-the-gaps pharmacare program — he read the bill also. If drugs that are currently covered by provincial and territorial governments and private insurance providers do not remain covered on the same terms, the program would cost $5.7 billion over five years, not $1.5 billion.

I was concerned whether employers would continue to provide their employees with their existing insurance coverage for drugs if those drugs were fully covered by the government. When the Parliamentary Budget Officer appeared before the Social Affairs Committee, I asked him whether there is a market-based incentive for private insurers to reduce or eliminate their coverage for drugs that would be covered under a universal public plan. Mr. Giroux, the PBO, responded:

Absolutely. If the government is providing a regime that covers 100% of prescription drugs for diabetes and contraceptives, whereas private plans have to incur these costs, there is obviously an incentive for [employers] to say that they’re removing it through collective bargaining, for example, and to tell employees [that if you] go to the federal government to get the 20% that is not covered; you might as well go for 100%. . . . That is such an incentive that I am talking about and that you are referring to in your question . . . .

On September 27, less than a week before clause-by-clause consideration, the Chair of the Social Affairs, Science and Technology Committee, Senator Omidvar, received a letter from Minister Mark Holland that was then distributed to the full committee. In his letter, the minister wrote:

For additional clarity, this standard of coverage means that all residents of a participating province or territory will be eligible to receive free access, without co-pay or deductible, to a range of contraception and diabetes medications. Under this program, 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.

Hmm. Now are we even more confused?

It would seem, then, that medications that are currently covered by private insurance providers will not remain covered on the same terms. The Parliamentary Budget Officer anticipated $2.5 billion in cost recovery due to private drug plan coverage. Without that cost recovery, this phase of pharmacare is estimated to cost $4.4 billion and is, therefore, underfunded by approximately $2.9 billion.

At second reading, I observed that the proposed list of diabetes drugs is very restricted. On February 29, 2024, on the same day that Bill C-64 was tabled in the other place, Health Canada published a backgrounder on its website with lists of the contraceptives and diabetes medications to be discussed with the provinces and territories as bilateral agreements are negotiated. By my count, the list includes 70 birth control drugs and devices but 18 diabetes drugs.

In a brief to the Social Affairs Committee, the Canadian Life and Health Insurance Association shared an analysis of the lists in the Health Canada backgrounder. They wrote that in 2023, workplace benefit plans covered approximately $1.7 billion in diabetes medications. Per their analysis, 85% of those costs would not be covered under the formulary in the Health Canada backgrounder. Regarding contraception, they wrote that in 2023, workplace benefit plans covered approximately $217 million in contraceptives, and only 21% of those costs would not be covered under the formulary in the Health Canada backgrounder.

You can see that organizations advocating for contraception coverage were pleased with the list. However, organizations representing Canadians with diabetes found the list most inadequate.

Monica Kocsmaros, the Chief External Relations Officer at the Juvenile Diabetes Research Foundation, told the Social Affairs Committee:

. . . based on consultations with health care providers and those living with Type 1 . . . we would like to see the ultimate list that is developed reflect what is in the clinical practice guidelines established by Diabetes Canada. It is important that physicians have therapeutic options to address the wide variations in individual patient responses to and tolerance of any particular drug [and] that patients can access these, as one insulin may work well for one person and not another. It is very individualized care. And as health care providers refer to these clinical practice guidelines, the insulin listed on them should be available for patient care across the board.

Laura Syron from Diabetes Canada noted:

The limited formulary makes individualized care nearly impossible and may negatively impact our health-care system and the health of people living with diabetes by offering sub-optimal therapies . . . . Also, a national pharmacare program with a limited formulary has the potential to impact choice; health-care providers may look to the formulary as a definitive list without collaborating with the person living with diabetes and discussing all therapeutic options.

In a brief to the Social Affairs Committee, the Canadian Generic Pharmaceutical Association expressed concern about the limited formulary. They wrote the following:

CGPA and its Biosimilars Canada division are concerned that the limited list of drugs covered under the pharmacare plan will lead to sub-optimal prescribing to the medicines made available to the public for free, leading to sub-optimal health outcomes for patients. We are also concerned that the lack of a comprehensive approach to universal coverage may provide a disincentive for public drug plan formularies to continue their coverage of a broad range of prescription medicines, and provide a disincentive to expand coverage to include new drugs in the future. These same concerns also apply to employer-sponsored drug plans.

At committee, I asked Mr. Keon the following:

What happens to a diabetes patient, for example, who has tried maybe 10 different drugs? None have been very effective, and then they try the eleventh drug, it’s effective and they want to stay on that drug. But then they go to the universal plan, and that drug is not in that formulary.

Mr. Keon replied, “We would be concerned that they wouldn’t have full coverage.”

A huge potential unintended consequence is that employers may stop providing coverage for diabetes and contraceptive drugs in their workplace benefit plans. Ms. Syron from Diabetes Canada used herself as an example. She said:

I’m on two drugs to manage my diabetes. One is on the current formulary attached to this legislation and one is not. Right now, the one that is not covered is covered by my private insurance.

If my private insurance decided to stop covering that, then I would have to pick up that cost myself.

The unintended consequences would be that, financially, people may actually be worse off in terms of being able to afford the drugs. The very purpose of this bill is to get more people on the right drugs, but the unintended consequence could be that fewer people are on the right drug . . . .

Stephen Frank, the President and CEO of the Canadian Life and Health Insurance Association, said:

For the majority of Canadians, this legislation as it is currently written will eliminate existing prescription drug coverage paid by employers for these medications. It will limit choice. It will use scarce federal dollars to replace existing coverage, and it will leave a huge gap of uninsured Canadians who rely on other medications beyond diabetes drugs and contraceptives.

When I asked the minister about this concern, he said, “On the idea that people would lose coverage, I don’t see that. People have a choice.”

I replied:

. . . they might not have a choice because their private insurer might say, “Sorry, we don’t cover it any longer. Go to the province or the feds and get covered.”

That is the point. You’re saying that I, as an individual — for example, I have private insurance — have the choice to stay with my private insurer or go to the public insurer, meaning the federal government and the provincial arrangement. However, my private insurer might no longer cover me. In fact, it might start to be a gradual process of loss of private insurance.

The minister insisted that this would not happen. However, his eleventh hour letter to the Chair of the Standing Senate Committee on Social Affairs, Science and Technology on Friday, September 27 indicates that Canadians with private insurance are already on track to lose their coverage for diabetes and contraceptive drugs.

At second reading, I pointed out that Bill C-64 includes few definitions of important concepts in this program, which has led to unnecessary confusion.

Indeed, the Standing Senate Committee on Social Affairs, Science and Technology heard from almost all our witnesses that Bill C-64 would have been a much better bill had it included important definitions to add clarity instead of maintaining confusion. Even the key terms of “universal,” “single-payer” and “first-dollar” have not been defined. Suggestions were made to broaden the definition of “pharmacare” to include the critical role of pharmacy services, which have been completely omitted.

When asked whether a bill that limits drug coverage to those who have no coverage would go against the principle of universality, the Parliamentary Budget Officer, Mr. Giroux, responded, “That’s a good question. It depends on how you define universality.”

Professor Matthew Herder, the Director of the Dalhousie Health Justice Institute at Dalhousie University, has studied and written extensively on the issue of pharmacare. He called this bill “. . . fundamentally ambiguous.”

Asked by the chair whether this bill, ambiguities and all, is better than no bill at all, Professor Steven Morgan, an economist and professor of health care policy at the University of British Columbia, said:

As the legislation is currently written, I think no legislation is better than this legislation. I say that as someone who has spent 30 years working on this file in Canada.

Confronted with the same question, Professor Marc-André Gagnon, a political economist with Carleton University’s School of Public Policy and Administration, replied, “Sadly, I don’t know.”

This bill’s lack of definitions only adds to its opacity and ambiguity.

At second reading, I raised the concern that the national universal pharmacare policy envisioned by Bill C-64 infringes on provincial jurisdiction and complicates or interferes with programs that the provinces and territories already have in place.

In a press release issued at the close of the Council of the Federation meetings in Halifax in July, Canada’s premiers reiterated their wish for the federal government to stay in its lane. They said:

Federal engagement with provinces and territories has become increasingly limited and inconsistent, as the federal government seeks to unilaterally advance programs in areas of provincial and territorial jurisdiction.

Our federation works best when all orders of government respect constitutional authority. In recent years, federal actions have repeatedly encroached on provincial/territorial jurisdiction without adequate consultation, collaboration or funding. When the federal government unilaterally overreaches through legislation, regulation, selective investments and taxation in areas of provincial and territorial responsibility, Canadians end up with ill-suited one-size-fits-all programs that are underfunded and do not meet the needs of residents in all regions of the country. . . .

At a press conference at the close of their summer meeting, Premier François Legault of Quebec observed:

Federal interference in provincial jurisdictions is a problem which is becoming worse and worse from budget to budget. . . . These intrusions create management problems. They double the size of bureaucracy. This is not desirable.

Premier Dennis King of Prince Edward Island lamented what he called “jurisdictional creep.” He said:

I think every Canadian would expect that all of their levels of government should try to pitch in and do everything they can to make their lives a little bit easier, but it gets . . . a little bit frustrating with the duplication and the overstepping . . . of the federal government.

In an interview with CPAC, Newfoundland and Labrador Premier Andrew Furey said:

If the federal government decides that it wants to have an impact on what could arguably be provincial jurisdiction . . . tell us how we can be partners. But to wake up one morning and hear that, you know, there’s potential pharmacare or potential dental care, which is . . . provincial jurisdiction, with no consultation or collaboration . . . I mean, that’s where I have concern about the shape-shifting of the Constitution.

In an interview with the New Brunswick Telegraph-Journal, Premier Blaine Higgs said the following of the federal-provincial relationship:

Things are strained to say the least . . . . And I would say that it’s dysfunctional in many ways.

Premier Higgs added that there hasn’t been a general meeting between the premiers and the Prime Minister for years. Their last meeting, in February 2023, dealt solely with health care.

B.C. Premier David Eby echoed the call for a meeting between the premiers and the Prime Minister. He told reporters:

It’s not about money. It’s not about additional funding, it’s about, can we co-ordinate nationally on these areas of shared interest?

Premier Eby continued, “And that is where it sometimes feels like we’re just beating our head against a wall . . . .”

And at the Standing Senate Committee on Social Affairs, Science and Technology, Alberta’s Minister of Health, Adriana LaGrange, said:

The federal government continues to bring forward health initiatives as a way of pursuing its own political goals when its actual responsibility is to act as a good partner on the long-term sustainability of health initiatives and improved health outcomes. Provinces and territories have exclusive jurisdiction over the planning, organization and management of our health care systems. . . .

. . . The federal government must respect provincial and territorial jurisdiction and the decisions we make. Federal initiatives, such as pharmacare, must be developed in a way that is truly collaborative, aligns with provincial and territorial priorities, and respects jurisdictions.

On Tuesday, in this chamber, when Senator Gignac spoke to this bill, he said, “. . . Ottawa should be less critical and show some humility before encroaching on provincial jurisdiction with new initiatives.” I agree.

There are also other outstanding concerns regarding Bill C-64, such as the administration of pharmacare, the composition of the committee of experts and the powers, functions and governance structures of the Canadian Drug Agency. I thank my colleague Senator Osler for capably reminding us of these weaknesses in the legislation.

In conclusion, colleagues, I am not convinced that Bill C-64’s approach to pharmacare is prudent, not fiscally nor as policy. I would have fully supported a bill that ensured pharmacare coverage for the most vulnerable — those who have no insurance or who are underinsured. But with this bill, the government will spend at least half of its pharmacare budget for Canadians who already have comprehensive coverage with their own private plans. The Parliamentary Budget Officer made this point decisively in his testimony before the Social Affairs Committee.

It is relevant here to remember my earlier point about universality. Universal pharmacare coverage does not mean that the state is exclusively responsible for prescription drug costs, nor does it mean that the plan must be publicly administered. France, Germany and the Netherlands have universal, statutory, multi-payer pharmacare systems that have more in common with the Quebec model than with the model proposed in Bill C-64.

The Social Affairs Committee heard persuasive evidence that Bill C-64 could result in the erosion of private insurance, leaving many Canadians worse off than they are today — with a very restricted formulary, drug shortages and reduced pharmacy services.

Frankly, for myself, colleagues, it could not be clearer: I cannot support Bill C-64 as it is currently written. Thank you.

Would Senator Seidman take a question?

Of course I will.

Thank you, Senator Seidman, for your very thoughtful speech. It is evidently clear that this is a bill that is a lot more aspirational than it is logical, pretty much like I guess the Trudeau government in general.

Yesterday, we had a colleague invoking the founders of medicare in this chamber, Tommy Douglas, Prime Minister Diefenbaker and Pearson. I was wondering: What do you think the founders of medicare would have to say about the fact that today we have a government over the last nine and a half years that not a single fiscal year did they transfer over funds that were equitable to what the provinces spend in providing health care? If anything, they have been reducing the transfer payments to health care considerably over the last nine years, and, of course, not respecting the Canada Health Act, which has a number of fundamental principles including being comprehensive, accessible and, most importantly, universal.

With more than 6 million Canadians and families without doctors today, in 2024, what would Tommy Douglas, Prime Minister Diefenbaker and Prime Minister Pearson have to say about the state of health care?

Thank you. That’s a big question. I have to tell you that probably they would say what all of us say, and that is that the health system is failing us badly. I think finally Canadians are getting the courage to say that the system isn’t working. How many of us have family members, friends and neighbours who struggle with the health system? They don’t have general practitioners, for example. I know countless numbers of people who go to clinics and don’t have any continuity of care as a result. We all hear it and read it. I think we are gradually recognizing that the system is failing us.

We have been very sensitive about our health system. We have praised it, loved it and there is no question that the concept was excellent. But if we look around to the rest of the world now, we’ll see that a lot of countries that started with the same system as Canada started with have moved beyond it and have found other ways of ensuring their population receives the kind of care they need.

Senator Seidman, during the Standing Senate Committee on Social Affairs, Science and Technology’s study of Bill C-64, we received briefs from the Canadian Organization for Rare Disorders and the Canadian Forum for Rare Disease Innovators. They outlined the concerns that implementation of a national pharmacare program could further delay the implementation of the National Strategy for Drugs for Rare Diseases, which is referenced in clause 5 of Bill C-64. Have you reviewed the briefs, met with any of the groups and can you share any of your thoughts or concerns about delaying the implementation of the rare disease strategy?

Actually, yes, I can say that I have read the briefs, but I also did meet with representatives of the Canadian Organization for Rare Disorders, Dr. Durhane Wong-Rieger, who is the president of that organization. I do say that I noted at second reading that the government announced investment of up to $1.5 billion over three years in support of the National Strategy for Drugs for Rare Diseases. That was in March of 2023. And $1.4 billion of that $1.5 billion was to be allocated through bilateral agreements. The rare disease community really celebrated, they were very excited about that. But it has been more than a year and a half and only one bilateral agreement has been signed.

In the other place, Dr. Durhane Wong-Rieger, the President and CEO of the Canadian Organization for Rare Disorders, warned the Standing Committee on Health that given the lack of promised progress on rare diseases, what does it say in terms of the prospects for the success of the pharmacare legislation? In fact, she said it is unconscionable and unethical to introduce a program designed to transform and save lives and then fail to execute on it.

I have to say I totally agree that the government has to follow through on its commitments to the rare disease community and ensure that the bilateral agreements for rare disease drug funding are not overshadowed by this new situation where they now have to negotiate bilateral agreements because of Bill C-64.

Are senators ready for the question?

Is it your pleasure, honourable senators, to adopt the motion?

All those in favour of the motion will please say “yea.”

Some Hon. Senators: Yea.

The Hon. the Speaker: All those opposed to the motion will please say “nay.”

Some Hon. Senators: Nay.

The Hon. the Speaker: In my opinion the “yeas” have it.