Statements & Speeches

Bill C-64, An act respecting Pharmacare – Second Reading

June 18, 2024

Honourable senators, I rise today as the opposition critic to speak at second reading to Bill C-64, An Act respecting pharmacare. I want to thank Senator Pate, the sponsor of Bill C-64, and Senators Osler, Moodie, Simons, Bernard and Duncan for their insights on this important piece of legislation.

Part 1        Part 2

I will now look at the bill.

Colleagues, Bill C-64 seems to propose two distinct policies. On the one hand, Bill C-64 proposes national universal pharmacare and sets out the essential principles that the Minister of Health is to consider when working toward the implementation of this policy.

On the other hand, the bill codifies a structure and processes which oblige the Minister of Health to make payments to those provinces with which the federal government has made bilateral agreements in order to increase any existing public pharmacare coverage for specific prescription drugs and related products intended for contraception or the treatment of diabetes. It’s a tale of two policies.

Colleagues, I will consider some of the issues that confront us in Bill C-64, both in the proposal for national universal pharmacare and the incremental plan for drugs and products intended solely for contraception or the treatment of diabetes. I will also consider three overarching, structural concerns which I believe should be examined at committee.

The national universal pharmacare framework proposed in Bill C-64 seems to express principles in keeping with the policy envisioned by A Prescription for Canada: Achieving Pharmacare for All, the final report of the Advisory Council on the Implementation of National Pharmacare.

The advisory council was launched in June 2018 and chaired by Dr. Eric Hoskins. Its final report, published in June 2019 and often referred to as “the Hoskins Report,” proposed “. . . the government enact national pharmacare through new legislation embodying the five fundamental principles in the Canada Health Act. . . .”

In keeping with the Hoskins Report, commitments have been made for foundational elements, including the Canadian Drug Agency, the National Formularly and the National Strategy for Drugs for Rare Diseases.

In 2021, the federal government invested $35 million with Prince Edward Island for the Improving Affordable Access to Prescription Drugs Program as a kind of pilot study for fill‑in‑the-gap coverage.

In 2022, a multidisciplinary national panel convened by the Canadian Agency for Drugs and Technologies in Health, or CADTH, at the request of Health Canada, recommended a framework for developing a national formulary and a sample list of drugs.

In March 2023, the National Strategy for Drugs for Rare Diseases was launched with an investment of up to $1.5 billion over three years to increase access to and the affordability of drugs for rare diseases.

In December 2023, the Canadian Drug Agency was created with an investment of $89.5 million over five years starting in 2024-25.

Bill C-64, the government asserts, is the next step toward national universal pharmacare. However, there are considerable weaknesses to this particular proposal for national universal pharmacare. As my colleagues often hear me emphasize around proposed legislation, there may be serious unintended consequences. Let’s explore that.

First, the national universal pharmacare policy envisioned by Bill C-64 infringes on provincial jurisdiction and complicates or interferes with programs the provinces and territories already have in place.

As we understand, in Canada, provincial and territorial governments are responsible for the management, organization and delivery of health care services for their residents. Quebec — which requires that all residents who do not have private drug insurance must enrol in the province’s premium-based public plan — is the only province to have achieved universal drug coverage. Given this, Quebec’s government objects to Bill C-64.

In February, the office of Christian Dubé, Quebec’s Minister of Health and Social Services, told The Canadian Press:

The Quebec government has repeatedly pointed out that health is an exclusive Quebec jurisdiction. If the Government of Canada goes ahead with this drug insurance project, the Government of Quebec will demand the right to opt out with full compensation . . . .

Quebec is not alone in this objection. The Government of Alberta has expressed similar sentiments.

All provincial and territorial governments offer prescription drug coverage programs, albeit of different types, for their residents. Let me provide just an overview of some of the public programs across Canada which cover prescription drugs, medical devices and supplies. Some are based on income, some are based on age, and some add specific disease entities, which require expensive medications.

Alberta has a plan that covers adults from low-income households with high ongoing prescription needs or who are pregnant; children in low-income households; residents who are 65 years of age and older; and the Non-Group Coverage program — administered by Alberta Blue Cross — which charges monthly premiums and is available to all Albertans.

British Columbia has a plan that covers residents receiving income assistance; residents of licensed residential care facilities; and Fair PharmaCare, which helps B.C. families pay for prescription drugs. Fair PharmaCare is based on income — the less a family earns, the more assistance they receive.

Manitoba’s Pharmacare program provides income-tested benefits for residents whose prescription costs are high.

New Brunswick has a plan that covers residents over 65 years of age; those in a nursing home; children in the province’s care; social development clients; and a plan that provides income‑tested benefits for residents who do not have private insurance.

Newfoundland and Labrador has a plan that covers low‑income individuals and families; and residents over 65 years of age who receive Old Age Security and the Guaranteed Income Supplement.

The Northwest Territories has a plan that covers eligible residents 60 years of age and older and residents diagnosed with specific diseases, and a plan that covers Indigenous Métis residents.

Nova Scotia has a plan that covers all residents without any other drug plan, or who have excessive drug costs.

Nunavut has a plan that covers seniors and residents diagnosed with certain illnesses, and residents receiving income support.

Ontario has plans that cover residents over 65 years of age; residents receiving social assistance; residents in long-term or special homes; residents receiving home care; and residents with high prescription drug costs — based on income — who do not have private coverage or another provincial plan. And Ontario has a plan that covers more than 5,000 drugs at no cost for anyone 24 years of age or younger who is not covered by a private plan.

Prince Edward Island has a plan that covers low-income families; residents 65 years of age and older; residents under age 65 who do not have drug insurance; and residents who need assistance to pay for drugs and supplies for a range of specific medical conditions. Further, in 2021, P.E.I. entered into a partnership with the federal government for a pilot program that reduced co-pays for eligible medications to $5 — including medications for cardiovascular disease, diabetes and mental health — for residents covered under certain programs.

In Quebec, the Public Prescription Drug Insurance Plan covers all residents who are not covered by a private plan.

Saskatchewan has a plan that covers all residents except those on federal programs.

The Yukon has a plan that covers residents over age 65 and children from low-income families, and that provides benefits for Yukon residents who have a chronic disease or a serious functional disability. Our colleague Senator Duncan has very well described their plan in much more detail.

Depending on program design, national universal pharmacare could simplify the complex array of programs in place across Canada. But there is institutional knowledge regarding program delivery in each of our provinces and territories, and there are tailored programs in place to meet the needs of our communities. Quebec, for instance, has almost 30 years of experience with its program.

Furthermore, most Canadians do have existing drug coverage. Statistics vary depending on the source you reference. As the Advisory Council on the Implementation of National Pharmacare notes in the Hoskins report:

Our research turned up different estimates of how many Canadians are uninsured or underinsured: some studies put the number of uninsured at 5 per cent of Canadians . . . . Other surveys tell us closer to 20 per cent of Canadians . . . are either uninsured or underinsured . . . .

Those who don’t have existing drug coverage may be eligible for a program in which they are not enrolled. In a 2022 pan‑Canadian analysis of prescription drug insurance coverage, The Conference Board of Canada estimates that more than 97% of Canadians are eligible for some form of prescription drug coverage. That leaves a 2.8% gap of Canadians who are not eligible for coverage. In addition, The Conference Board of Canada notes that approximately 10% of Canadians are not enrolled in a public or private plan for which they are eligible.

Second, the national universal pharmacare policy contemplated by Bill C-64 may have a negative impact on pharmacists’ practice. In testimony to the Standing Committee on Health in the other place, pharmacists expressed concerns about a national universal pharmacare plan. Joelle Walker from the Canadian Pharmacists Association highlighted the administrative burden involved in switching patients from one plan to another:

. . . the potential for significant disruption can’t be overstated. . . . changing drug plans can be very disruptive for plan members and for pharmacists.

The reality is that public drug plans across Canada are far less comprehensive than private plans, which means that if the legislation shifts patients from their private plans to a public plan, pharmacists and physicians will likely have to spend a considerable amount of time switching patients to new therapies, especially if their drug is no longer covered under a public plan; filling out paperwork to get special exemptions; and communicating these changes to patients.

Benoit Morin, President of the Association québécoise des pharmaciens propriétaires, told the Standing Committee on Health that under a public single-payer principle, dispensing fees would be a single amount negotiated for covered drugs. He explained that this would have a significant impact on Quebec proprietor pharmacists because dispensing fees are higher for drugs covered by private plans, including the private component of Quebec’s Public Prescription Drug Insurance Plan.

Here’s the importance of that point. He said:

The current funding of Quebec pharmacies relies mainly on professional fees associated with the dispensing and monitoring of prescription drugs. Variations in those fees can influence pharmacies’ ability to provide services to patients. . . .

It is precisely the flexibility of the present mixed public‑private model that enables Quebec pharmacies to develop, operate in all regions and provide a host of services to patients. . . . Without that flexibility, the financial health of the pharmacy network would be undermined, and the impact would be even greater in remote regions.

Mr. Morin also noted:

Some 371 pharmacies shut down when a universal plan was introduced in New Zealand.

We’re afraid that, if there’s no mixed system in Quebec, pharmacies will find it hard to be profitable, which will result in closures and force them to set up in major centres rather than rural areas.

The federal government has a pattern of not consulting pharmacists on policies which will directly impact both them and the Canadians whom they serve. In a press release issued after Bill C-64 was tabled in the other place, the association lamented that there were no pharmacists on the 2018 Hoskins Advisory Council on the Implementation of National Pharmacare.

The care that Canadians receive at pharmacies is irreplaceable. According to research conducted for the Canadian Pharmacists Association by Abacus Data in September 2023, 37% of Canadians visit a pharmacy at least once a month, and 23% speak with a pharmacist at least once a month.

Pharmacists’ scope of practice varies across the country, but, depending on jurisdiction, pharmacists can prescribe medications, make therapeutic substitutions and change drug dosages, formulations, regimens, et cetera. In all provinces and in the Yukon, pharmacists can inject drugs and vaccines. In Alberta and Quebec, pharmacists can even order and interpret lab tests.

Pharmacists’ scope of practice continues to grow. As more and more Canadians report not having a family doctor, a majority of those surveyed by Abacus agreed that expanding the range of services offered at pharmacies — including walk-in clinics for common ailments, vaccinations, testing and lab services, chronic disease management and prescribing contraception — would enhance access to and quality of health care.

Such ambitions could be realized in a context in which local pharmacies can thrive. In an op-ed in The Hill Times, Sandra Hanna, a community pharmacist and pharmacy owner in Guelph and the Chief Executive Officer of the Neighbourhood Pharmacy Association of Canada, notes that:

Over the past few years, pharmacies and their teams have played an increasingly important role as primary health-care providers, particularly in rural and remote regions. . . .

She warns, however, that a single-payer pharmacare program would cost the pharmacy sector $1 billion annually, which is equal to cutting approximately 20 million pharmacist hours.

Currently, Canadians have excellent access to pharmacies. According to Organisation for Economic Co-operation and Development, or OECD, data, in 2021, Canada had 30 pharmacies per 100,000 population, more pharmacies than the OECD average. Can we, in our current health care ecosystem, afford to jeopardize the success of our pharmacies and pharmacists? This is a potential unintended consequence that we should examine at committee.

Third, the national universal pharmacare policy contemplated by Bill C-64 could erode access to drugs and exacerbate drug shortages. The Standing Committee on Health, or HESA, heard from several stakeholders who were concerned that, depending on the ultimate contents of a national formulary, the national universal pharmacare plan proposed in Bill C-64 may worsen drug availability.

Angelique Berg, the President and Chief Executive Officer at the Canadian Association for Pharmacy Distribution Management, told the committee:

. . . Because they run so efficiently, reduced funding means that distributors have few options left but to reduce services. Some examples are that they could stop carrying money‑losing products . . . reduce safety stock . . . or reduce delivery frequency to high-cost regions . . . .

. . . When the government awards a contract to a single manufacturer, that firm effectively becomes a monopoly, so competitors have little incentive to stay in the market. Concentrated marked power increases the risk of limited supply, and therein lies our concern.

The Canadian Pharmacists Association shared Ms. Berg’s concern about drug shortages. Ms. Walker said:

One thing that we’ve noted is that the number of available medications in each drug class can decrease significantly, depending on how many companies are in the market, and we are most vulnerable to drug shortages if only one or two manufacturers are producing a particular drug.

Let’s say that there’s a national disaster in one country that’s producing some of the API, and the one company there can’t produce that drug, and the other companies aren’t able to readily increase their production. . . . there’s a really complicated ecosystem that this pharmacare approach needs to also recognize.

The Montreal Economic Institute has also flagged concerns that if national universal pharmacare was implemented in Canada, drug distribution could be interrupted. They write:

. . . if certain drugs are no longer covered by an insurance plan, it is very likely that pharmaceutical companies will stop distributing them in Canada. The variety of medications in circulation in this country is therefore at risk of shrinking, preventing previously covered patients from having access to these drugs, even if they were disposed to pay for them out of their own pocket.

Drug shortages are not uncommon in Canada. In December 2018, I asked the Leader of the Government in the Senate about a Canada-wide shortage of the antidepressant Wellbutrin. In February 2020, I asked about a shortage of tamoxifen, a drug used as part of hormone therapy to treat breast cancer. In June 2020, I asked about shortages of thyroid drugs, inhalers, blood pressure medication and glaucoma eye drops. In November 2022, I asked about a shortage of pediatric amoxicillin.

Pharmacists already navigate drug shortages in Canada. Committee hearings should carefully consider the unintended consequences of fewer available medications in Canada.

Honourable senators, I will continue to address some of the issues that confront us in this plan and the possible unintended consequences.

The fourth issue I bring to your attention is the national universal pharmacare policy contemplated by Bill C-64. It has no mechanism for exceptions to be made to allow a patient to access a drug that is not on the formulary.

This concern was raised at the House of Commons Standing Committee on Health by John Adams, Chair of the Board of Directors of the Best Medicines Coalition. The Best Medicines Coalition represents 30 patient organizations from Parkinson’s, arthritis, hemophilia and blindness to cancers and other complicated and rare diseases.

He told the House of Commons Health Committee:

. . . not every patient responds in the same way to the same drug. We need some variety and some choice. Quebec has a mechanism where a doctor can apply to a truly independent scientific review committee that is outside of the health bureaucracy for a drug that the doctor knows the patient needs . . . .

It would be a great improvement for national pharmacare, as a concept, to always have that safety valve for the exceptional patient.

Committee hearings should examine the merits and potential mechanisms for exceptions to the formulary.

Fifth, costs for a national universal pharmacare program, as outlined in the principles of Bill C-64, could balloon.

In its report on Bill C-64, published on May 15, the Office of the Parliamentary Budget Officer:

. . . assumes that any medications that are currently covered by provincial and territorial governments, as well as private insurance providers will remain covered on the same terms.

They state, and the language is really important, “. . . The aim of the program is to expand and enhance, rather than replace . . . .”

This assumption informed the PBO’s estimate that universal national pharmacare will increase federal program spending by $1.9 billion over five years.

In my briefing with department officials, I was assured that the government, in its bilateral agreements with the provinces, will negotiate to ensure that the provinces maintain their own current public plan coverage for diabetes and contraception. However, there is no way for the federal government to guarantee that private drug plans will maintain their coverage.

If private drug plans were to cease providing coverage for diabetes and contraception drugs and devices, according to the PBO public program spending would more than double. Instead of costing $1.9 billion over five years, the program would be projected to cost $4.4 billion over five years.

Honourable senators, aside from the stated “universality” principles, the actual propositions in Bill C-64 oblige the Minister of Health to make payments to provinces and territories with which the federal government has made bilateral agreements to provide coverage for specific prescription drugs and related products intended for contraception or the treatment of diabetes.

Clause 6(1) of the bill specifies that the payments are intended to “. . . increase any existing public pharmacare coverage . . . .” The wording of this clause informed the assumptions made in the PBO’s report on Bill C-64.

The wording of clause 6(1) seems to indicate that the coverage for specific prescription drugs and related products intended for contraception or the treatment of diabetes would fill gaps in existing coverage.

This seems to contradict other clauses in the bill. Is it confusing? Indeed it is. As Stephen Frank, the President and Chief Executive Officer of the Canadian Life and Health Insurance Association, told the House of Commons Health Committee:

. . . in Canada there are 27 million Canadians with private drug coverage. It’s very broad coverage, much broader even than that of the best public system available across Canada, and they value that coverage greatly—90% of them value their coverage to a high amount or to a great amount—so they want to protect it and they are very strongly opposed to having it put at risk. Overwhelmingly, if you ask them what their preferred approach is and you give them a choice, they would like government to target their efforts to where the need is.

Colleagues, should we displace the existing coverage that 90% of Canadians value?

Confusion remains regarding how private insurance and this new public plan would be coordinated at the pharmacy counter. If a patient has existing private coverage for 80% of the cost of a medication, will the public plan cover the remaining 20%? Or will 100% of the cost shift to the public plan, thereby shifting costs from the private insurer to taxpayers?

In my briefing with department officials, when asked, they replied that these “back office” details had not yet been worked through. In its study, committee hearings should pursue answers to these foundational questions.

Coverage for specific prescription drugs and related products intended for contraception or the treatment of diabetes will not be administered centrally by the federal government, unlike the new dental benefit. Instead, the new coverage will be administered by the provinces and territories in accordance with forthcoming bilateral agreements.

Bilateral agreements entail myriad challenges. For instance, in March 2023, the government announced an investment, as I already said, of up to $1.5 billion over three years in support of the National Strategy for Drugs for Rare Diseases, which is supposedly part of this plan. This is meant to help increase access to, and affordability of, promising and effective drugs for rare diseases.

It has been more than one year, and those bilateral agreements have not been signed and, as a result, that money has yet to help Canadians with rare diseases.

Dr. Durhane Wong-Rieger, the President and Chief Executive Officer of the Canadian Organization for Rare Disorders, or CORD, told the House of Commons Health Committee:

. . . we’ve seen that the majority of that money, $1.4 billion out of $1.5 billion, is to be allocated through bilateral agreements. . . .

What we know is that, well over a year later, none of these agreements have been put in place. We don’t even know if there have been discussions around them. Whether it’s just bureaucracy, whether it’s just the cumbersome nature of the process, whether it’s really hard to get provinces to agree, I don’t know. However, this is not the way it’s needed to be.

Dr. Wong-Rieger wondered whether other medications would suffer the same tardiness in rollout as the drugs for rare diseases. Committee hearings would benefit from CORD’s lessons learned.

We have heard over the years how very difficult it is for the federal government to get comprehensive and comparable data from the provinces, even if data reporting is a requirement of a bilateral agreement.

For example, late last year when the Social Affairs Committee was studying Bill C-35, An Act respecting early learning and child care in Canada, we heard from Gordon Cleveland, who is the chair of the National Advisory Council on Early Learning and Child Care’s Data Indicators and Research Working Group. He told us:

. . . . the trouble is that the provinces and territories, in many cases — either haven’t been able to —

— improve data collection —

— or it’s not high enough of a priority. They are not reporting in the way the agreements foresaw. They’re not providing information in as timely a way as we thought they would, and even when they do, there will be major problems of lack of comparability.

If, as the minister has indicated, coverage for specific prescription drugs and related products intended for contraception or the treatment of diabetes is to be a pilot project for more universal coverage, then we will need excellent data for evaluation purposes. Colleagues, committee hearings should consider whether bilateral agreements can facilitate such data collection by including data-specific requirements.

The Government of Canada will be launching discussions with provinces and territories based on the list of diabetes drugs attached to a backgrounder published on Health Canada’s website on February 29, 2024. In that backgrounder, the government also announced its intention to establish a fund to enable work with provincial and territorial partners to support Canadians’ access to supplies that diabetics require to manage and monitor their condition and administer their medication, such as syringes and glucose test strips.

Many stakeholders have weighed in on the list provided in the backgrounder. The Association québécoise des pharmaciens propriétaires noted:

If you compare Quebec’s formulary to the one being proposed, even though it’s not final, you can see that several millions of diabetes-related prescriptions would be lost. . . . we manage stock shortages every day in community pharmacies. . . . We really need to ensure that this formulary at least covers Quebec’s formulary, even though the Quebec one is generous.

Broad coverage is needed for diabetes. . . . This wide range of covered drugs is essential in maintaining the health of Canadians.

Furthermore, the proposed fund for medical supplies for diabetics is, at this point, no more than a commitment. It is not included in Bill C-64. Mike Bleskie, an advocate with Type 1 diabetes, told the House of Commons Health Committee that his out-of-pocket costs stand at about $450 per month, mostly from his continuous glucose monitor, which is not covered in Ontario, and his insulin pump supplies. Bill C-64 would not help diabetics with those expenses.

Committee hearings should include the potential consequences of such a limited formulary and should study the formularies of different jurisdictions, both within Canada and internationally.

Colleagues, there are three other overarching problems with Bill C-64 that should be examined at committee. The first is the lack of oversight of the newly created Canadian Drug Agency, or CDA.

Bill C-64 envisions a broad and important role for the Canadian Drug Agency. Part 7 of Bill C-64 explains that the CDA will advise the minister on the clinical effectiveness and cost effectiveness of prescription drugs and related products compared to other treatment options; the prescription drugs and related products that should be included in prescription drug coverage plans in Canada and the conditions of that coverage; the collection and analysis of data on prescription drugs and related products; information and recommendations to be provided to health care practitioners and patients on the appropriate use of prescription drugs and related products; and improvements to be made to the pharmaceutical system, including through greater coordination between health system partners, patients and other stakeholders. It’s a big list.

The Canadian Drug Agency, or CDA, will prepare the national formulary that will inform the Minister of Health’s discussions with the provinces, territories, Indigenous peoples and other partners and stakeholders regarding national universal pharmacare. The CDA will also develop a national bulk purchasing strategy for prescription drugs and related products.

The problem, honourable senators, is that the Canadian Drug Agency was established at the direction of the Minister of Health, not by legislation. Serious questions should be asked as to whether, instead, the CDA should be subject to parliamentary oversight, the Access to Information Act, Auditor General scrutiny and interventions by a patient ombudsperson.

In his testimony at Standing Committee on Health, or HESA, John Adams of Best Medicines Coalition elaborated:

This bill gives the minister substantial new powers. It could be improved by building in various forms of transparency and accountability . . . .

. . . I think it defers too much to the black box called the Canadian drug agency and doesn’t put transparency or accountability mechanisms around what could become a very important role in system reform. . . .

The second overarching problem is that although the CDA will advise the minister on the creation of the national formulary, decisions regarding which drugs will be included will ultimately be made by the minister. This is an extraordinary power.

In her testimony before HESA, Linda Silas, the President of the Canadian Federation of Nurses Unions, said:

. . . when I met the minister yesterday, I said that it wasn’t really up to him to decide what was on the formulary, which diabetic drug, and that a group of experts should deal with it. . . .

Committee hearings should consider whether it is appropriate for the minister on the advice of an agency that is not overseen by Parliament — to decide what drugs and devices will be listed on the national formulary.

The third overarching problem with Bill C-64 is its lack of definitions. This concern was raised by many members of Parliament and stakeholders during HESA’s study.

Clause 6(1) of the bill tasks the minister with making payments to provinces or territories:

. . . in order to increase any existing public pharmacare coverage — and to provide universal, single-payer, first-dollar coverage — for specific prescription drugs and related products intended for contraception or the treatment of diabetes.

But the bill does not define “universal,” “single-payer” or “first dollar.” This has led to unnecessary confusion. Committee hearings should include the consideration of amendments to the bill to introduce definitions.

According to the Canada Health Act:

In order to satisfy the criterion respecting universality, the health care insurance plan of a province must entitle one hundred per cent of the insured persons of the province to the insured health services provided for by the plan on uniform terms and conditions.

This is how Canadians have understood the term “universal” since 1985.

Although Canadians may have an intuition as to what “single‑payer” means, the term must be defined. As a 2017 article in the Journal of General Internal Medicine notes:

Single-payer systems are heterogeneous. Acknowledgment of what is considered as single-payer and the characteristics that are variable is important for nuanced policy discussions on specific reform proposals.

The government should be asked to provide a precise definition of “single-payer” so that the term can be defined in Bill C-64.

The term “first dollar” has also caused confusion. At HESA, Michelle Boudreau, the Associate Assistant Deputy Minister in the Strategic Policy Branch of Health Canada, explained that:

. . . “First dollar” means that as soon as an insurable event occurs — in this case, having a prescription filled — the insurance would apply: That is, the coverage would apply before any other payments.

Similarly, the Canadian Medical Association defines “first dollar coverage” as, “Health services covered 100% by public insurance, with no charges to patients seeking care.” This would seem to indicate that there will not be coordination of benefits when a patient has private insurance.

If public coverage will apply before private coverage, the government has underfunded its program:

Budget 2024 proposes to provide $1.5 billion over five years, starting in 2024-25, to Health Canada to support the launch of the National Pharmacare Plan.

The Parliamentary Budget Officer, or PBO, meanwhile:

. . . estimates that the first phase of national universal pharmacare will increase federal program spending by $1.9 billion over five years. . . .

We must remember, however, that the PBO’s estimate:

. . . assumes that any medications that are currently covered by provincial and territorial governments, as well as private insurance providers will remain covered on the same terms.

If medications for contraception and diabetes that are currently covered by private insurance providers are instead covered by the public plan, the PBO estimates that this phase of pharmacare will cost $4.4 billion. There would therefore be a $2.9 billion dollar budget shortfall.

The government must explain what precisely is meant by “first dollar,” and the committee should consider amending the bill to include this definition.

The Hoskins report says:

. . . Canada is the only country in the world with universal health care that does not provide universal coverage for prescription drugs. . . .

However, colleagues, universal coverage need not mean single-payer coverage. We can endorse universal coverage without endorsing a system funded exclusively by the federal government.

In conclusion, honourable senators, when Bill C-64 is sent to committee, there is much to consider — even as for the very essence of what is being proposed in this legislation. Is it indeed a universal system, as we understand the concept, or is it a fill‑in‑the-gap system? There seems to be confusion even about these very principles.

Colleagues, Canadians are counting on us.

Thank you for your attention. I look forward to study at committee.