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A pharmacist counts prescription drugs at the CentreTown Pharmacy, in Ottawa, on June 12, 2019.

CHRIS WATTIE/Reuters

When it comes to national pharmacare, nobody can accuse the federal Liberal Party of failing to do its homework.

In the 18 months before Justin Trudeau presented his party’s health-care platform at a medical sciences building in Hamilton on Monday, the Liberals received two exhaustive studies totalling 312 pages of advice on pharmacare.

The first, prepared by the Liberal-dominated parliamentary standing committee on health, was published in April of 2018 after the committee heard two years of testimony from 99 witnesses.

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The second, prepared by a Liberal-appointed national advisory council, was released in June after the panelists held in-person consultations in every province and territory, absorbed 15,000 responses to an online questionnaire and pored over more than 150 written submissions.

Both fact-finding exercises came to the same conclusion: Canada should establish a universal, single-payer public pharmacare program that does for prescription drugs what medicare did for medically necessary services offered in hospitals and doctors’ offices.

After all that, it was a touch deflating for some pharmacare enthusiasts when Mr. Trudeau unveiled a health platform that promised only a “down payment” on national pharmacare − and a relatively small down payment at that, considering the numbers thrown around in the national advisory council’s report.

About 20 per cent of Canadians, or more than 7.5 million people, are estimated to be either uninsured or underinsured for prescription drug costs. A national pharmacare plan would address that, and aim to save billions of dollars. Globe health reporter Kelly Grant explains.

“Instead of announcing that the recommendations of the national advisory council would be implemented if the Liberals are re-elected, they’ve instead used softer language,” said Nav Persaud, a family doctor and a University of Toronto professor who holds a Canada Research Chair in health justice. “That raises the concern that they’re not prepared to stand up to the pressure.”

So what, exactly, are the Liberals promising on pharmacare? And how does their plan stack up against the pharmacare commitments from the NDP and the Green Party, the other parties that have made pharmacare a central feature of their pitch to voters?

The Liberal plan

The health plan that Mr. Trudeau revealed on Monday promises an additional $6-billion over the next four years, representing a cost of $750-million in 2020-2021, rising to $1.75-billion in 2023-2024.

But that money is not solely for national pharmacare. It is for all of the Liberals’ enhanced health-care commitments, including making sure all Canadians have access to a family doctor or a primary health-care team; setting clear national standards for access to mental-health services; improving access to home care and palliative care; and implementing national pharmacare, “guided by the recommendations of the Advisory Council on the Implementation of National Pharmacare."

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The Liberals know that nothing on that list can be accomplished by federal fiat. In Canada, health-care delivery is a provincial responsibility, which is why Mr. Trudeau acknowledged that a re-elected Liberal government would have to negotiate with the premiers to make its health agenda − including its pharmacare agenda − a reality.

The national advisory council acknowledged that, too. Its final report urged the federal government to pick up the entire incremental tab of pharmacare as a way of enticing the provinces and territories to take part.

Council Chair Eric Hoskins, a former Ontario Liberal health minister who understands the strain health already put on provincial budgets, knew pharmacare would struggle to get off the ground otherwise.

Although the report predicted that the bulk-buying power of a single government payer would contribute to Canada spending about $5-billion less per year on drugs than it would if the existing private/public system remained intact, the $5-billion is a savings to all types of payers, including workplace insurance plans and Canadians who pay out of pocket.

As the full cost shifted to federal and provincial governments, the council predicted a starter version of pharmacare covering essential medicines would cost an extra $3.5-billion a year and a full-blown program would cost an additional $15.3-billion.

“[The Liberal plan] falls short by a pretty wide margin − a billions-of-dollars margin,” said Michael Law, a University of British Columbia professor who holds a Canada Research Chair in access to medicines.

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“Even with the starter plan under Hoskins, all of the money [the Liberals] have put forward for all of health care isn’t enough to pay for that.”

The NDP plan

NDP Leader Jagmeet Singh reinforced his party’s long-standing commitment to pharmacare by rolling out its Medicine for All plan in the spring, five months before the campaign kicked off.

Mr. Singh is promising to adopt legislation, modelled on the Canada Health Act, that would see Ottawa provide a pharmacare transfer to the provinces and territories contingent on the jurisdictions offering universal coverage and adhering to a national formulary, a list of evidence-backed medicines covered for all.

If a drug is on the NDP’s formulary, at least one version would available at no cost; patients who want a brand-name drug when a generic is available would pay a $5 co-pay.

An arm’s-length body would set the formulary and negotiate discounted prices with drug companies, the NDP plan says. (The Liberals promised $35-million over four years in their latest budget to establish a similar body, which they are calling the Canada Drug Agency.)

The NDP has promised $10-billion a year for the federal portion of pharmacare. They’ve also promised to implement pharmacare by the end of next year, prompting Dr. Law of UBC to say, with a chuckle: “That would be very hard.”

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Rushing could have negative consequences, he warned, especially for people transitioning from private to public drug insurance.

But Dr. Persaud of U of T said there were no significant technical barriers to setting up pharmacare on the NDP’s timeline, only political ones.

The Green Party plan

Elizabeth May and the Green Party also vow to enact universal pharmacare by next year, but they are promising to spend even more than the NDP to make it happen.

Their plan, guided by the recommendations of the parliamentary standing committee on health, would see Ottawa pick up the full cost of pharmacare for the first two years, after which the provinces and territories would, together, be expected to pay just over half the annual cost.

The Parliamentary Budget Officer (PBO) pegged the cost of the Green plan at $26.76-billion in 2020-2021, rising to nearly $40-billion (including the provincial contributions) in 2028-2029.

The Greens and the NDP are both well back of the Liberals and Conservatives in the polls.

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“But if the Liberals end up with a minority government supported by the NDP and the Greens and the Bloc, then we may have a much more interesting outcome when it comes to a pharmacare system,” said Katherine Fierlbeck, a political-science professor at Dalhousie University.

The Conservative position

The Conservatives haven’t made any specific campaign announcements about pharmacare, other than to issue a news release criticizing Mr. Trudeau for declining, during his Hamilton health-care announcement, to explicitly rule out a ban on employer drug coverage. (For the record, the advisory council report that the Liberals say is their lodestar has as its third recommendation that, “Canadians be allowed to purchase private insurance to supplement coverage under national pharmacare.”)

Conservative Leader Andrew Scheer has poured cold water on proposals for national pharmacare in the past. When the national advisory council released its report in June, he said: “I don’t believe that anyone thinks that when Liberals announce multibillion-dollar spending programs that they’re going to save money.”

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