'We have a practical problem that needs a pragmatic solution,’ says Chris Bonnett
Canada has spent the better part of a decade talking about national pharmacare. And after all the studies, bilateral deals, and political promises in recent years, the country has very little to show for it.
"Where it stands today is not any meaningful improvement for most Canadians," said Chris Bonnett, principal consultant of H3 Consulting. "I believe that it was a squandered opportunity.”
He situates the current effort in a long history, noting it is roughly the 10th or 11th serious attempt at a national drug program since the Second World War, each one led by Liberal governments and each one ultimately derailed by cost pressures, political tensions, or constitutional limits on federal power in health care.
“We have a practical problem that needs a pragmatic solution. Using those words, framing it that way, we'll probably get much more traction with Ottawa than some kind of idealistic approach whose opportunity was decades ago,” said Bonnett. “[Carney’s] strategically inclined and we could be strategically inclined as a private payer community to address this issue.”
Bonnett believes the latest iteration of Pharmacare was set up to fail, noting the design as a fully publicly funded universal plan clashed with an entrenched private drug insurance system that already serves about two-thirds of Canadians. He questions why policymakers would try to rebuild from scratch something that has become structurally embedded over five decades, especially without first making a compelling, evidence-based case for the scope of the problem.
“We had the Gap study from Innovative Medicines that was helpful to identify the uninsured and the people who have access but have not applied for access. But that's only part of the problem. In my experience, in my research, it’s the smaller part of the problem. The bigger part is the underinsured, the people with complex health conditions, the people who need specialty drugs, the people who need drugs for rare disorders that have six and seven figures. We don't have a good feel for who they are, what their circumstances are, and therefore, how to tailor coverage and interventions to help them.”
According to Bonnett, surveys from CLHIA and Neighbourhood Pharmacies have found Canadians like the idea of pharmacare in principle but are protective of the drug coverage they already have. Looking across the data, he sees that most people can already access a public, provincial, or federal plan, and for the majority that coverage works reasonably well.
“There isn't this huge unmet need. The unmet need is very tailored, and it's tailored in groups that don't necessarily have a big voice in political or policy decisions,” said Bonnett.
Instead, the gaps are concentrated in specific groups that have little political influence: part-time workers, employed people without benefits, and residents of provinces where coverage is noticeably weaker than in neighbouring jurisdictions. Because most voters feel adequately covered, there is no groundswell of public pressure for change.
That lack of public demand feeds into a lack of political will. Pharmacare is not a vote winner, he argues, and it is competing with a difficult fiscal environment marked by large deficits and rapidly growing public debt. Taken together, those factors make the current pharmacare model politically and financially unviable, and without both public support and political interest, he believes it was never going to advance in its present form.
Sandra Hanna, CEO of Neighbourhood Pharmacies also underscores the priority should be the people who have fallen through the cracks entirely, not duplicating coverage for those who already have it.
She sees the current model – universal first-dollar public coverage for diabetes and contraception – as a misallocation. While she supports ensuring access to those drug categories, she argues the money would go further if it were directed at uninsured Canadians rather than layered on top of benefits people already receive through existing public or private plans.
"A targeted approach with a broader formulary would be more effective at filling those gaps than a broad approach with a smaller formulary," she says.
On the implementation side, Hanna flags coordination as a pressing concern. Four jurisdictions have signed bilateral agreements, two have already begun rolling out the program, and others are expected to follow in the coming months. She stresses that provinces need to work closely with insurers, pharmacy benefits managers, and pharmacies ahead of launch to avoid confusion at the counter. After all, pharmacists are the ones fielding questions from patients when coverage issues surface.
Hanna frames the broader opportunity in fiscal terms. In a health care environment stretched thin by competing demands, she argues Canada cannot afford a pharmacare model that spreads resources across populations that do not need the help.
"We could be more targeted in our approach to prioritizing those who do not have insurance … so that we can have a more fiscally responsible or cost-effective solution to address those in most need, while also preserving additional funding for the many other health care challenges that we have today in the system," she said.
Bonnett believes the real challenge lies in integration, noting there’s no consistent framework connecting private coverage, provincial plans, and federal programs. That structural gap needs to be addressed, he said.
“This massive duplicative structure was promoted consistently over the last decade. We need to find a solution that is appropriately narrow and focused, as well as affordable and sustainable financially and logistically. If we could do that, then we could make Pharmacare far more useful than simply pouring more money into duplicating coverage that employers and trusteed plans already willingly provide to plan members.”
One of the biggest obstacles over the past decade, Bonnett argues, was the lack of a unified industry voice. Notably, insurers, pharmaceutical companies, pharmacy associations, health professionals, and labour unions were all pushing different messages, leaving government unsure of who to listen to and afraid of making enemies.
“To the extent that those stakeholders could come together and have a collective, unified and constructive approach to government … [it would] make it much, much easier for governments to understand what they could do and how they could work together to solve the problem," he added.
Hanna underscored how ongoing education is essential, making sure federal and provincial policymakers understand the breadth of coverage already in place, the role drug plans play as a core part of employer benefits packages, and how satisfied most Canadians are with what they have.
Meanwhile, the sustainability challenges facing some private plans, she notes, are not being addressed by the current pharmacare programs, which largely duplicate what most plans already cover as standard.
She wants stakeholders across the drug benefits space – insurers, pharmacies, benefits providers – to rally around a unified message: that a group of uninsured Canadians exists and needs to be prioritized, but not at the expense of disrupting coverage that is already working.
"We are all aligned around the concept of universal coverage and being defined as everyone having coverage. So coverage for everyone, but that doesn't necessarily have to be through a single payer," she said.
