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Sean Speer: A single-payer pharmacare model would be costly—and even worse, ineffective and unnecessary

Commentary

Minister of Health Mark Holland speaks about new national pharmacare legislation in Ottawa on Thursday, Feb. 29, 2024. Patrick Doyle/The Canadian Press.

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. 

Sarah Teich: Canada’s proposed law to battle foreign interference is a good start but still needs work

Commentary

Prime Minister Justin Trudeau appears as a witness at the Public Inquiry Into Foreign Interference in Ottawa, April 10, 2024. Sean Kilpatrick/The Canadian Press.

The federal bill aimed at countering the long arm of foreign interference and transnational repression in Canada is strong but not strong enough.

Bill C-70, tabled May 6, proposes various amendments to the CSIS Act, the Security of Information Act, and the Criminal Code. It would also, if passed, enact the long-awaited foreign influence registry, the Foreign Influence Transparency and Accountability Act.

In one crucial area of improvement, it is critical that Canadian authorities communicate with individuals who are targeted by foreign interference and transnational repression. To date, in many instances, this has not happened. A high-profile example of this occurred last year. When news broke that threats had been made against Conservative MP Michael Chong by agents of the Chinese government, it became evident that Canadian authorities had failed to disclose those threats to Chong or his family.

Bill C-70’s amendments to the CSIS Act would allow information to be disclosed if the disclosure “is essential in the public interest” and if “that interest clearly outweighs any invasion of privacy that could result from the disclosure.” The addition of Section 19 (2.1) to the CSIS Act appears to provide an alternative path to disclosure of threats, but only if the information does not contain any personal information of a Canadian or person in Canada, or the name of a Canadian entity or corporation. While disclosure could never be permitted in all instances—Canadian law must always balance privacy rights—it is not clear if these amendments go far enough in striking the proper balance.

On the other hand, the proposed amendments to the Security of Information Act are significant and strong. Under the new Section 20 (1), every person who “at the direction of, for the benefit of or in association with, a foreign entity or a terrorist group, induces or attempts to induce, by intimidation, threat or violence, any person to do anything or to cause anything to be done” could be found to have committed an offence.

Section 20 (2) broadens the extraterritorial application of this offence, and sections 20.1 (1), 20.2 (1), 20.3 (1), and 20.4 (1) create additional offences. Critically, Section 20.4 (1) could help protect vulnerable political processes, such as nomination contests, from foreign interference. Finally, proposed amendments to Section 22 of the Security of Information Act widen the act’s preparatory offences and raise the maximum penalty for their commission.

Further, the enactment of a foreign influence registry would enable greater transparency regarding foreign influence in political and governmental processes. Anyone besides diplomats and other exempted persons who enter an arrangement with a foreign principal would be required to register within 14 days and provide information as to that arrangement.

However, the kind of information that must be registered will be outlined in regulations that have yet to be made. Section 4 of the foreign influence registry act necessarily limits these requirements to political and governmental processes, thereby excluding instances of foreign influence that occur in other realms.

While it is encouraging that a commissioner of foreign influence would be able to conduct investigations and would be given the powers to compel witness attendance and document production, it is likely that enforcement of registration requirements will prove challenging. Foreign interference and transnational repression may be carried out with the involvement of proxies and proxy organizations, and the provision of indirect benefits, which may present challenges in investigations and enforcement.

Bill C-70 is also limited by what it noticeably lacks. Amendments to the Criminal Code are restricted to the sabotage offences, the first offence of which already existed. It does not create a specific foreign interference offence, nor does it create the offence of refugee espionage, which is criminalized in some European countries. Strikingly, Bill C-70 does not propose the addition of a definition of “transnational repression” to the CSIS Act or to any of the other pieces of legislation it proposes to amend or enact.

Overall, Bill C-70 is a good bill, with numerous significant amendments. However, it is not even close to a panacea. Further laws are needed, as well as policies, to ensure that acts of foreign interference and transnational repression are appropriately criminalized, to ensure that law enforcement authorities have the tools and the training to respond to such instances, and to ensure that victims of foreign interference and transnational repression have proper recourse and protection.