It has been a dramatic week for the Royal Canadian Navy and the government of Canada. The situation could be straight out of any coming-of-age teen drama as Canada, confident as can be, is cruising around a house party only to stop dead when they see their rival, posted up by the punch bowl, smirking and flirting with the host: “What are they doing here?”

The setting, in this case, is Havana, Cuba, where the RCN’s HMCS Margaret Brooke^{1The HMCS Margaret Brooke is one of the new class of Arctic Offshore Patrol Vessels (AOPS) currently being deployed by the RCN, but it is not a major surface combatant like the Halifax-class frigates or forthcoming Canadian Surface Combatant. As its name alludes to, the class of vessel is lightly armed and intended to undertake less demanding patrols in places like the Arctic or the Caribbean to provide security and humanitarian support.} was participating in a port of call. The arriving rival? Five Russian naval vessels visiting their Caribbean ally. While this may all seem like an overblown coincidence, the entire series of events illustrates some of the strengths of the Canadian military’s capabilities and, more importantly, some of its long-standing weaknesses in policy formation and implementation.

What is a port of call?

For the uninitiated, port visits have come to occupy a critical place in Canada’s diplomatic and security policy over the past decade. While they have a very long tradition, since 2015 the government has made a significant effort to use them to cultivate diplomatic relations with states, particularly in the Indo-Pacific. During a visit, the local ambassador and Global Affairs Canada (GAC) in Ottawa will organize events around the ship.^{2Much of the research for this article is based on a forthcoming chapter on the RCN’s role in Canada’s Asia-Pacific policy development 2015~2022, in Kenneth M. Holland, ed., Canada and Competing Indo-Pacific Visions of China and the US: Caught in a Foreign Policy Dilemma. London: Palgrave Macmillan, 202} This includes hosting delegations and meetings on the vessel, arranging shore visits, and engaging in humanitarian activities.

Planning a port visit usually occurs months before a vessel departs for a deployment as they require an extensive inter-departmental process. A request to undertake a port visit to Havana, given its sensitivities, would almost certainly come from GAC and/or the prime minister’s office. In these cases, they should be viewed more as a very high-level diplomatic event, with the PMO and the minister of foreign affairs directly involved. From here, the military starts studying the requests’ feasibility as naval vessels tend to have packed itineraries over a deployment—there are exercises with allies, temporary secondment to ongoing multilateral operations, and other port visits that all pull on a schedule.

In this case, it is highly unlikely that the idea would have originated from within the Department of National Defence. Cuba is not an ally, and there are very limited military benefits that would be accrued from a port visit.^{3The RCN presence in the Caribbean has not been large but had some notable successes. A major mission in the region has been Operation CARIBBE, a long-running joint counter-narcotics operation with the United States. In addition, the Navy rushed the HMCS Glace Bay and Moncton from the West coast of Africa to Haiti as the security situation in that country deteriorated. While it had extremely limited consequences on the crisis, Canada’s modest contribution was well received by other regional allies.} They are particularly troublesome for crews, requiring a number of additional measures to secure the vessels and personnel in port, as well as extensive diplomatic negotiations. These considerations are part of the reason why visits to Cuba occur relatively infrequently.^{4The RCN has not undertaken a port visit to Cuba since 2016, when the Halifax Class HMCS Fredericton visited the country as part of the Trudeau government’s efforts to thaw relations with the Communist state.}

It’s been an eventful several months in Canadian policy and politics. Hub readers would therefore be forgiven for missing the Trudeau government’s Bill C-64 which would establish a public insurance model for diabetes drugs and contraception and set out a process to extend the single-payer principle across a broader range of pharmaceuticals. Notwithstanding the government’s claims otherwise, the pending legislation represents a fundamental threat to Canada’s mixed model of drug coverage including for the millions of Canadians who are satisfied with their current access to medications and drugs.

We’ll return to the possible consequences of the legislation later. It’s worth spending a minute on how Canada’s current system works. The Medicare model provides for single-payer and universal public insurance for hospitals and physician expenses. The remainder of health-related expenditures, which actually represent the majority of total health-care spending, are paid through a combination of private insurance, targeted public insurance schemes based on age and means, and out-of-pocket spending.

Drug coverage is a good example. The vast majority of Canadians have some form of drug insurance to defray the cost of purchasing medication. More than 60 percent of us have private insurance—mostly provided through our employers. Another 20 percent (the majority of whom are seniors) are covered through public plans. There remains a small share of the population that relies mostly on out-of-pocket spending.

This mix has evolved over the decades and generally works well. The majority with private insurance are able to access a wide range of drugs sometimes fully covered by their insurance provider and sometimes with co-payments. Polling tells us that these Canadians are satisfied with their access to and the cost of drugs.

The Trudeau government and single-payer proponents nevertheless marshal different arguments against the status quo, including that it is too expensive and leaves some people uncovered. Their solution is to replace the current mixed model of drug coverage with a new, taxpayer-funded single-payer model that would provide first-dollar coverage for drugs. One way to think about it is that pharmacare aims to bring drug coverage into the pre-existing Medicare model.

There are some inherent downsides to blowing up the status quo. The first is that it would disrupt the insurance model for the vast majority of Canadians for whom it is working in order to help the small number who are uninsured or underinsured. From the point of view of scarce public resources, this just doesn’t make sense. There are better and more affordable options to target those in need without wiping out the insurance of millions of Canadians and bringing them onto the public dime.

The second problem is that in part due to the extraordinary expense (which the Parliamentary Budget Office estimates to be roughly $40 billion per year) the government could only reasonably offer single-payer coverage by narrowly constraining the drugs available. Pharmacare proponents argue that such rationing would be based on an objective understanding of the costs and benefits of different medications but that’s a pretty unsatisfactory answer for those who will lose access to drugs that they’re currently using as they’re pushed from a private plan to the public one.

This isn’t an abstract point. The pending legislation’s coverage of diabetes medication and contraction is a case in point. As Mediave Blue Cross CEO Bernard Lord set out in a recent episode of Hub Dialogues, the government’s plan would cover something between one-half and two-thirds of the drugs currently available under most private plans. If single-payer pharmacare was extended more broadly, it means that Canadians could potentially lose access to a significant share of presently insured medications.

As part of the legislative debate, the Trudeau government has argued that single-payer doesn’t necessarily mean that private plans would become superfluous or outlawed. But single-payer has a legal and practical meaning. If the government wants to establish a public model that provides a floor for those in need that operates in parallel with private insurance, then it ought to amend the legislation to codify this point rather than merely hope that judges and regulators adopt a new definition of single-payer.

Especially since the legislation stipulates that within 30 days of its passage, the federal minister of Health must establish a panel of experts to provide recommendations on “options for the operation and financing of national, universal, single-payer pharmacare.” This legislative language has real meaning and could have real consequences for Canadians and their access to drugs.

It’s a fallacy to think that single-payer insurance is the only means to achieve the goal of universality. As Lord outlined in our conversation, we’re already close to universal coverage and there are different options, including expanding targeting public plans or increasing the generosity of the Medical Expense Tax Credit, in order to close the gap.

Canadians can have universal drug coverage. We don’t need to give up the parts of the system that are working or consolidate into a single government program to get there.

This article was made possible by the Canadian Life and Health Insurance Association and readers like you.