OTTAWA — Dr. Eric Hoskins has always thought of pharmacare as a nation-building project.
Six years before Prime Minister Mark Carney catapulted the words “nation-building” to the top of his political agenda, Hoskins used the same language when he issued a landmark report calling for Canada to implement universal, publicly funded drug coverage.
“In Canada, we know that great national projects can go well beyond building things that we can see with our eyes,” Hoskins wrote in 2019, after concluding the work of a Justin Trudeau-era council assessing the merits of such a program.
“We, too, can be the kind of generation that builds a national project that changes Canada for the better.”
When the Star spoke to Hoskins this month, the person who once breathed new life into a decades-long debate over public drug coverage in Canada wasn’t so sure the policy met the prime minister’s economically oriented definition of nation-building.
Those projects — which include ports, mines, and potentially pipelines — are at the heart of Carney’s ambitious effort to shield Canada from a geopolitical “rupture” he says was prompted by trade shocks south of the border. They can be fast-tracked thanks to a controversial law the Carney Liberals rushed through Parliament this summer, and projects identified for acceleration will be guided by several criteria, like protecting Canada’s autonomy, to be considered truly in the national interest.
Everything Hoskins heard about the law was “so focused on physical infrastructure,” however, that the former Ontario health minister couldn’t imagine how a program that would give all Canadians access to prescription drugs could possibly fit among a pantheon of pipelines and port expansions.
But as he mulled the idea over in his head, a vision began to take shape.
“It was only when I started looking at the criteria that I realized, yeah, pharmacare does fit this one, and it does fit this one, and it does fit this one,” Hoskins said.
Despite a Liberal government that has signalled that health is not part of its crisis mandate, the idea that health care should also be a nation-building endeavour appears to be taking hold.
The Star spoke to some of Canada’s top history, economic and health-care experts and learned that the concept is being debated in university lecture halls, surfaced at this month’s federal-provincial health ministers’ meeting, and is backed by the chair of a federal pharmacare committee whose report on implementing universal, single-payer drug coverage is set to be released within weeks.
And it is universal pharmacare — a pricey policy opposed by powerful industries and whose future Carney is currently toying with — that some believe is the one health-care project that could achieve that vaunted status.
“Pharmacare is shovel ready,” says Dr. Danyaal Raza, a family physician and the Primary Care and Health Policy Scholar at St. Michael’s Hospital in Toronto.
“All the ingredients are there. If we were in a kitchen … all of the measuring cups are ready. They’re levelled off. The stove is turned on, and the water is at a boil.”
To understand the prime minister’s preoccupation with nation-building, you have to return to the time period he is seeking to evoke.
“We retooled entire sectors of this economy in the fight during the Second World War. And then we built hundreds of thousands of new homes in record time for returning heroes and their families. We built a new seaway to unlock the potential of the Great Lakes economy,” Carney said in September, when he announced billions in aid for tariff-struck sectors.
“Now, at this moment of profound change, we bear the same responsibilities, and we should have the same ambitions as those who came before us.”
In his bid to rekindle Canada’s wartime resolve, there is one element of the country’s postwar transformation the prime minister seems to shy away from: health care.
“As the war was coming to an end, the federal government decided to pull together the premiers at … the Dominion-Provincial Reconstruction Conference. They had been working on a set of proposals from about 1943 on, preparing for the end of the war, and that became known as the Green Book Proposals,” said Gregory Marchildon, a health policy, economics and history expert at the University of Toronto, and executive director of the 2001 Romanow Commission on the future of health care in Canada.
“It was very much an economic, financial and social revamping of the country. Part of the Green Book Proposals involved a very comprehensive health insurance program that was a package of coverage that would have included not just hospitals and medical care — as we have today in medicare — but also prescription drugs, and other basic services.”
Consensus on the 1945 proposals ultimately collapsed, partly due to squabbles over federal-provincial jurisdiction.
That failure spurred then-Saskatchewan premier Tommy Douglas to pick up the reins, introducing two years later a publicly funded coverage plan for hospital care in his province. The seeds of Douglas’ work morphed into a nationwide expansion of universal health coverage over the following decades, culminating in 1984’s Canada Health Act, a defining pillar of the nation’s identity.
“It’s the big, national, social projects that I think we’re remembered for, and there’s no better example of that than medicare,” Hoskins said. “Pharmacare was always, right from the get go, intended to be part of that.”
It’s not that Carney has entirely flicked health care off his to-do list, though the term appears nowhere in his government’s singular mandate letter.
“Health care is a priority of this government, as it is for Canadians, because you can’t build Canada strong without healthy Canadians,” read a statement to the Star from the office of federal Health Minister Marjorie Michel.
The prime minister has said that part of the rationale behind his looming “austerity” budget is that fiscal restraint would let social programs like dental care, child care, and pharmacare exist, though during his prebudget address on Wednesday, he excluded pharmacare from that list.
However, his government initially wavered on whether it would continue the work of the Trudeau Liberals by striking preliminary pharmacare deals with provinces and territories that had yet to reach such agreements.
(The previous government, as part of its alliance with the New Democrats, passed the Pharmacare Act in 2024 which sought to first cover diabetes and birth control drugs and devices and to lay out a road map for more comprehensive drug coverage later. The four deals struck so far were all Trudeau-era achievements.)
Carney eventually said in September that he did hope to ink more pacts, and Michel said last week at a meeting of health ministers in Calgary that talks with some provinces were “ongoing.”
When asked, however, whether Carney would commit to expanding those agreements to cover more classes of drugs for all Canadians — the vision of pharmacare the New Democrats and several expert reports have long called for — Carney said that was “a different question.”
“Unfortunately, the lasting value of a national pharmacare program is probably not salient enough in the mind of a government concerned about the economic crisis that we’re in this moment,” said Steve Morgan, a professor of health policy and pharmaceutical policy expert at the University of British Columbia.
But what if it was?
According to the Building Canada Act, there are five criteria Ottawa “may consider” before deeming a project to be in the national interest.
It should bolster the country’s autonomy, resilience and security. It should provide economic or “other” benefits. It should have a good shot at actually being completed. And it should advance the interests of Indigenous Peoples and contribute to Canada’s climate goals.
The type of pharmacare most advocates want to see the policy evolve into is a universal, single-payer model, where governments would foot the majority of prescription drug costs for all Canadians, regardless of their job or income. In 2023, the Parliamentary Budget Officer (PBO) estimated this model would cost federal and provincial governments $11.9 billion by 2025-26.
“For every dollar of that money that’s spent, somewhere on the order of a $1.25 of savings is generated for households and employers,” Morgan said.
Many of the economic benefits of a national program would come from lowering prescription drug costs. The country’s drug pricing regulator estimated Canada spent more than $41 billion in 2023, 43 per cent of which was paid for by governments, 37 per cent by private insurers, and 20 per cent by Canadians.
A single-payer program would increase Canada’s purchasing power and lower costs, some experts say, by making the government the sole buyer of drugs and ending manufacturers’ ability to negotiate prices with multiple purchasers.
The PBO estimated in 2023 that cost savings on drug expenditures would reach a modest $2.2 billion by 2027-28. Hoskins’ 2019 report pegged that number at $5 billion by 2027, while other research estimates the savings could be higher.
But it’s the trickle-down savings, something Morgan believes is less of an interest to Ottawa, where the rest of the economic case lies.
Those downstream impacts include strengthening the labour market by letting employers invest in their businesses instead of paying for costly private plans, letting more people stay in the workforce by improving their health, and ending “job lock,” where people chain themselves to unwanted jobs for fear of losing their benefits.
Hoskins’ report also outlines other savings, citing research showing that axing out-of-pocket costs for drugs treating just three health issues — diabetes, cardiovascular disease and chronic respiratory conditions — would lead to 220,000 fewer emergency room visits and 90,000 fewer hospital stays, as well as save the health-care system up to $1.2 billion a year.
Dr. Nav Persaud, a Canada Research Chair in Health Justice at the University of Toronto and physician at St. Michael’s Hospital, spent the last year chairing a federal committee that will soon publish its recommendations — as required under the Pharmacare Act — for launching and paying for a fully single-payer program.
He believes the tens of billions of dollars Canada shells out on prescription medications annually would be better spent within the country’s borders, bolstering domestic production capacity.
“Most of that money is going outside of Canada. It’s going to multinational pharmaceutical companies,” Persaud said.
It took a global pandemic for much of the country to realize just how little Canada could rely on itself in the face of a shattering public health crisis.
The gaps exposed by COVID-19 — the procurement chaos, supply chain woes, equipment shortages and expiring oversupply — make some believe pharmacare holds the potential to strengthen Canada’s autonomy and security, too.
For Morgan, a national pharmacare program could make buying a new drug conditional on manufacturers agreeing to maintain Canada’s stock through crisis and conflicts.
“A national pharmacare program that’s well-built … would definitely give Canada greater security in terms of protecting our sovereignty against the extraordinary power of multinational pharmaceutical companies,” Morgan said.
Morgan and other experts said that despite the realities of having to buy some medicines from foreign manufacturers, the pandemic should also inspire a national pharmacare program to support domestic manufacturing and supply.
“(The government) definitely could give preference to, and should give preference to, companies that are manufacturing the drugs and doing the research and development in Canada,” said the University of Toronto’s Marchildon.
“And these could be companies whose equity ownership is predominantly Canadian, so it’s a way to build up the pharmaceutical sector in Canada.”
Persaud said it’s not far-fetched to imagine the country ramping up its own production of medicines, pointing to the University of Toronto’s Connaught Laboratories, which decades ago manufactured vaccines and other treatments like insulin for Canada and other countries before it was privatized and sold to foreign companies.
“We’ve done it before, and we can do it again,” he said.
It would take time for Canada to fully reap the benefits of a universal pharmacare program.
Something that wouldn’t take long would be putting a program in place.
“We actually have public drug plans in every single jurisdiction in this country. Even the federal government has a public drug plan for the populations it’s responsible for. So we actually have all of that policy infrastructure,” said Raza, on the criterion that a nation-building project must have a strong likelihood of successful execution.
“Without a doubt, within six months, Canada could be running a national pharmacare program … especially if we started with a list of, say, 100 essential medicines that every Canadian would have access to,” said Morgan.
“It’s about as ready as any nation-building enterprise could be, because you’re not going to build a new highway or a high-speed railway within six months.”
There are signs of success at the provincial level, said Michael Law, a professor of health policy at the University of Calgary.
Law recently co-authored a study that looked at the impact of British Columbia’s universal coverage for contraceptives, and said researchers found the program “increased the use of the most effective form of contraception quite effectively.”
What’s more, such a program could also support the other two criteria for nation-building consideration. Persaud said a universal plan could reduce inequities faced by Indigenous Peoples (who are less likely to take medications as instructed due to cost concerns and are not all eligible for public plans), and could promote the use of clinically effective medications with fewer environmental impacts (due to humans expelling drug compounds into water systems.)
Finally, Persaud said, unlike the extensive regulations and consultations that have slowed progress on resource and infrastructure projects — the reason for introducing the major projects law in the first place — national pharmacare doesn’t come with the same kinds of barriers.
“What pharmacare is missing is the prime minister’s signature,” Persaud said.
Canada’s insurance industry, pharmaceutical companies, and other business groups feel otherwise.
They oppose a truly universal program — one that would end the country’s patchwork of private and public plans — and instead back a version of a “fill the gaps” model where public-funded coverage is offered only to those without existing plans.
The Canadian Life and Health Insurance Association (CLHIA), which represents the majority of the country’s life and health insurance companies, challenged the pharmacare law before its passage, arguing it could disrupt or negate workplace benefit plans, limit choice for Canadians who receive wider coverage under private plans, and presented a poor way to spend the public purse in the face of greater economic challenges.
The CLHIA declined to speak with the Star for this story, but wrote in a statement that Ottawa should focus on those without private drug coverage “while employer benefit plans continue to cover the 27 million Canadians who already have drug coverage through benefit plans.”
Joe Farago, the interim lead for government and stakeholder relations for Innovative Medicines Canada, an association of pharmaceutical companies, questions the idea of universal pharmacare as a nation-building project.
“If you’re taking limited public resources … and you’re now covering costs that were already covered on better plans, you’re limiting the value, or, let’s say, the nation-building value you could do,” he said.
Farago said that money would be better spent on improving out-of-pocket costs under provincial plans by reducing or eliminating deductibles, or listing more products covered by those plans.
He also pointed to feedback Canada’s Drug Agency recently received as it works on advising Ottawa on creating a national bulk purchasing strategy. Among the submissions, some companies indicated that combining public and private markets could increase drug costs rather than lower them, by reducing rebates governments receive from manufacturers.
Hoskins’ 2019 report, however, made the argument that Canada’s jumble of “more than 100 government-run drug insurance programs and more than 100,000 private drug insurance plans” had created an unfair system where some people pay more for medicines, some pay less, and some have no access at all. His council said it had heard from employers who questioned how long they could continue to afford to provide drug coverage.
IMC deals with innovative medicines: new medications just entering the market for which no copies, such as cheaper generics, are yet available.
“If you really want a nation-building exercise that meets the criteria, why not look at the innovative life sciences sector?” Farago said.
“We want to increase investments in science and medicine in Canada. We want clinical studies, research, coming to Canada.”
Farago said all of that can be done without a fully universal pharmacare program, and that such a program could actually de-incentivize innovative products from entering Canada because the private market “offers much faster access” to drugs due to the country’s “very slow approval process” in listing new products.
There came a point in many of the Star’s conversations with health-care experts where there was a human argument they wanted to make, rather than a political one.
Yes, robust and extensive economic arguments must be made when presenting the case for policies with billions of dollars attached. And no, a single-payer drug plan won’t generate the same number of jobs as high-speed rail or serve as a critical trade corridor.
But about the people behind those projects?
“If you don’t have your health, then you won’t have a job either,” said Dr. Margot Burnell, the head of the Canadian Medical Association, which felt compelled to use Carney’s “nation-building” language in its prebudget submission to the government.
As for Persaud, he said that when he heard about the Ottawa’s initial tranches of national interest projects, he understood their value, but found it hard to square the government’s enthusiasm with the inequities he sees daily.
There was a “disconnect,” Persaud said, between the political will for the projects and “people not being able to afford medicines or basics like food or transportation, things that people need to be healthy, to stay alive.”
Raza felt similarly.
“I think we are actively making people sick,” he said, thinking about his patients who show up in his office with uncontrolled or untreated health conditions.
“They don’t know what to do next. They don’t know how their life will unfold,” the physician added.
“All of these problems are avoidable, and they’re not avoidable in some abstract sense, like, ‘If only we could do something about it.’ This is avoidable harm that we can actively do something about now.”
