The first, fragile foundations of national pharmacare in Canada

On Oct. 10, 2024, Bill C-64 — comprising the first concrete measures to implement universal, single-payer, public pharmacare in Canada — became law.¹ As an initial step toward full national pharmacare, it is a laudable achievement. Yet the legislation is low on substance, high on promises and aspirations, and vulnerable to political change. This leaves people living in Canada mired in uncertainty as to when or whether they will have the guaranteed access to medications and therapies, regardless of ability to pay, that citizens of almost all other countries with a public health care system receive.

Without pharmacare, access to necessary medications is compromised for people in Canada who have no or inadequate private drug insurance, which leads to cost-related nonadherence to treatment and, ultimately, health inequities, increased health resource utilization, and unnecessary taxpayer-funded costs to health care systems. In this issue of CMAJ, Rebić and colleagues provide comprehensive new information on the prevalence of and factors associated with cost-related nonadherence to medications.² Using population-representative data from the Canadian Community Health Survey (2015–2020), they found that about 1 in 20 people in Canada reported cost-related nonadherence overall, but with much higher proportions in younger age groups, peaking among those aged 18–34 years. Other factors that were independently associated with cost-related nonadherence included lack of insurance, low income, female sex, and belonging to certain racial and ethnic groups, with the highest prevalence being among Black people.

The new legislation immediately commits federal funding to enable universal coverage for diabetes medications, devices, and supplies, as well as for contraceptive medications and devices. It will provide first-dollar coverage, meaning that coverage will be entirely funded by government with no deductible or out-of-pocket costs to patients, which is important for many of the benefits of pharmacare to be realized.³ The legislation further commits the federal government to a 1-year timeline within which to develop plans for a national formulary, a national bulk purchasing strategy for medications, a pan-Canadian strategy for appropriate use of medications and related devices, and how to operate and finance a full national pharmacare program. It also reaffirms the central role of Canada’s Drug Agency — formerly the Canadian Agency for Drugs and Technologies in Health (CADTH) — as the federal government’s chief advisor on which medical treatments are effective and worth paying for.

Given how closely cost-related nonadherence tracks with socioeconomic inequities, the government’s choice of diabetes and contraception as test cases for national pharmacare may seem sensible. Diabetes mellitus affects nearly 10% of people in Canada and disproportionately affects those belonging to equity-seeking groups, among whom 25% report having trouble affording diabetes medications.⁴ Coverage of oral contraceptives and intrauterine devices would help ensure that around 9 million women and gender-diverse people in Canada have control over their own reproduction. However, millions of other people with other common and disabling health conditions must continue to wait for the treatments they depend on to be covered.

Many individuals and Canadian institutions — including CMAJ — have long advocated for national pharmacare.^5,6 The new federal legislation does not deliver what CMAJ and others have called for; it is merely a first step — a pharmacare pilot program. It is paired with commitments to begin developing the key pillars that will be required to support full national pharmacare, but no commitments to build them. However, whether any of this will become reality is by no means assured. The federal government must negotiate with the provinces and territories to reach agreements on how payments for diabetes treatment and contraception will work. Although British Columbia has already signed on, Alberta and Quebec have indicated that they will not, leaving their residents with no guarantee that they will receive the intended benefits of this legislation. And with a federal election mandated to occur within the next year, whether the new law would survive a change in government is unclear. The leader of Canada’s Conservative party, currently leading in the polls, has already said he will reject it.

Some critics of the new pharmacare legislation — led by the insurance and pharmaceutical industries, which would stand to lose most from full national pharmacare — point to the high direct costs the new law would impose on governments and to current delays in medication coverage by public formularies compared with private insurance plans.⁷ This perspective ignores the broader cost savings, particularly for the private sector, expected from full national pharmacare, rendering its estimated overall net cost relatively low.⁸ However, addressing and allaying such concerns will clearly be important during the program development phase of the legislation over the next year.

Proponents of national pharmacare have also criticized the new legislation for merely filling gaps rather than creating a new system of coverage for everyone.⁹ A stepwise approach to minimize disruptions to the health care system is consistent with the recommendations of the federal government’s Advisory Council on the Implementation of National Pharmacare.¹⁰ However, by deferring the decision on how national pharmacare will operate and be financed, the law fails to ensure that pharmacare will be universal, single-payer, or public, even while highlighting these objectives as its core principles.

The passage of preliminary pharmacare legislation in Canada is a landmark, and history will likely record it as such. Although the nation’s pharmacare house remains unbuilt and the blueprints unfinished, Canada has at long last started to lay the foundation. Nevertheless, the government of Canada, and the people who elect it, need to ensure that the lot does not remain vacant indefinitely.

See related research at www.cmaj.ca/lookup/doi/10.1503/cmaj.241024