What If Canada Had Implemented National Pharmacare in 2018?

The Actual History

Canada's universal healthcare system, Medicare, has been a defining feature of Canadian society since the 1960s. However, unlike many other countries with universal healthcare, Canada's system has a significant gap: it does not include universal coverage for prescription medications outside of hospitals. This has created a patchwork system where:

Provincial Coverage: Each province and territory operates its own public drug plan, primarily covering seniors, those on social assistance, and in some cases, children and those with specific high-cost conditions.
Private Insurance: Approximately 60% of Canadians have private drug insurance, usually through employer-sponsored benefit plans.
Out-of-Pocket Expenses: Many Canadians pay for medications directly, with studies showing that 1 in 5 Canadian households includes someone who either doesn't fill prescriptions or skips doses due to cost concerns.

The idea of a national pharmacare program has been discussed in Canada for decades:

The 1964 Royal Commission on Health Services (Hall Commission) recommended that prescription drug coverage be included in Medicare.
The 1997 National Forum on Health, chaired by then-Prime Minister Jean Chrétien, recommended a universal public drug benefit.
The 2002 Romanow Commission on the Future of Health Care in Canada again recommended universal coverage for prescription drugs.

Despite these recommendations, implementation remained elusive due to concerns about costs, federal-provincial jurisdiction, and opposition from insurance companies and pharmaceutical manufacturers.

In 2015, Justin Trudeau's Liberal Party campaigned on improving prescription drug coverage but did not explicitly promise a universal program. After forming government, the Liberals took several incremental steps:

2017 Budget: The government announced the creation of a new department called the Canadian Drug Agency to negotiate better prices for prescription drugs.
Advisory Council: In 2018, the government appointed Dr. Eric Hoskins, former Ontario Health Minister, to chair an Advisory Council on the Implementation of National Pharmacare.
Hoskins Report: In June 2019, the Advisory Council released its final report, recommending a universal, single-payer public pharmacare system that would be implemented gradually, beginning with essential medicines by 2022 and comprehensive coverage by 2027.
2019 Election: During the 2019 election campaign, the Liberals promised to "take the critical next steps to implement national universal pharmacare," but without committing to the full Hoskins plan or a specific timeline.
COVID-19 Impact: The COVID-19 pandemic shifted government priorities and fiscal capacity, further delaying pharmacare implementation.
2021 Election and Beyond: The Liberals continued to promise pharmacare in subsequent campaigns and budgets, but by 2025, only modest steps had been taken, including some work on a national formulary (list of covered medications) and negotiations with provinces.

Throughout this period, the NDP consistently advocated for comprehensive universal pharmacare, while the Conservatives favored filling gaps in the existing system rather than creating a new universal program. The pharmaceutical industry and insurance companies lobbied against a universal public system, arguing for a "fill the gaps" approach that would maintain private coverage for those who already had it.

By 2025, Canada remained one of the few countries with universal healthcare that did not include universal coverage for prescription medications. Canadians continued to face a patchwork system with significant disparities in access and coverage, and prescription drug costs remained among the highest in the developed world.

This raises an intriguing counterfactual question: What if the Liberal government had moved decisively to implement a comprehensive national pharmacare program in 2018, following the appointment of the Advisory Council but before the 2019 election and the COVID-19 pandemic?

The Point of Divergence

In this alternate timeline, the divergence occurs in August 2018. After receiving preliminary findings from the Advisory Council on the Implementation of National Pharmacare, Prime Minister Justin Trudeau makes a bold political calculation.

Several factors contribute to this different decision:

Political Opportunity: With approximately one year remaining before the 2019 federal election, Trudeau recognizes that implementing a signature social program could energize progressive voters and create a lasting legacy comparable to Medicare itself.
Economic Analysis: Finance Ministry economists present models suggesting that while pharmacare would require significant upfront federal investment, the consolidated purchasing power would yield substantial savings within 3-5 years, potentially turning a political liability into an asset before the next election cycle.
Provincial Alignment: In this timeline, several key provinces—including British Columbia, Ontario (which had implemented OHIP+ for youth under the previous Liberal government), and Quebec—signal openness to a federal pharmacare initiative, creating a critical mass of provincial support.
Public Opinion: A series of high-profile media stories about Canadians rationing insulin and other essential medications creates a surge in public support for pharmacare, with polls showing 82% approval for a universal program.

On September 17, 2018, Trudeau announces the "Canadian Prescription Drug Plan" (CPDP) in a major speech at Toronto's Women's College Hospital, a site chosen for its historical significance in Canadian healthcare innovation. The plan includes:

Initial coverage of 200 essential medicines beginning July 1, 2019
Expansion to comprehensive coverage by January 1, 2022
A federal investment of $6 billion over three years, with projected net savings of $4.2 billion annually once fully implemented
A national formulary developed by an independent expert committee
Provincial participation through opt-in agreements with federal funding tied to national standards

The announcement catches opposition parties off guard. The Conservatives criticize the cost and federal overreach, while the NDP, though supportive of the concept, questions whether the plan goes far enough fast enough. The pharmaceutical industry and insurance companies immediately mobilize against the proposal, warning of job losses and reduced drug access.

Trudeau frames the initiative as the completion of Tommy Douglas's vision for Medicare and positions the Liberals as the party that delivers on healthcare. He announces that Health Minister Ginette Petitpas Taylor will lead implementation, with Dr. Eric Hoskins appointed as Special Advisor to the Prime Minister on Pharmacare Implementation.

The government introduces the Canada Pharmacare Act in October 2018, setting the stage for a dramatic transformation of Canadian healthcare.

Immediate Aftermath

Legislative and Implementation Process

The months following the announcement are characterized by intense political activity:

Parliamentary Battle: The Canada Pharmacare Act faces significant opposition in Parliament. The Conservatives attempt to delay the legislation through procedural tactics, while the NDP proposes amendments to accelerate the implementation timeline. After heated debate, the bill passes in February 2019 with Liberal and NDP support.
Provincial Negotiations: Health Minister Petitpas Taylor leads negotiations with provincial and territorial governments. British Columbia, Ontario, and the Atlantic provinces quickly sign on, while Alberta, Saskatchewan, and Manitoba express reservations but ultimately join to ensure their residents aren't disadvantaged. Quebec negotiates a distinct arrangement allowing it to administer its own program with federal funding, consistent with previous healthcare agreements.
Implementation Infrastructure: The government establishes the Canadian Drug Agency (CDA) as an independent body responsible for developing the national formulary, negotiating prices with pharmaceutical manufacturers, and overseeing the program's implementation. Dr. Hoskins is appointed as the agency's first chairperson.
Essential Medicines List: The CDA's expert committee works intensively to develop the initial list of 200 essential medicines, focusing on treatments for common chronic conditions, mental health medications, pain management, and life-saving drugs. The list is finalized in April 2019, covering approximately 80% of prescriptions written in Canada.
IT Systems Development: A significant challenge emerges in developing the information technology infrastructure to connect provincial health systems, pharmacies, and the federal payment system. The government contracts a consortium of Canadian tech companies to develop the platform, with a compressed timeline for the July 1 launch.

Economic and Industry Impacts

The economic implications begin to materialize quickly:

Pharmaceutical Industry Response: Major pharmaceutical companies initially threaten to delay launching new drugs in Canada and reduce research investments. However, the government's commitment to fair pricing rather than aggressive cost-cutting moderates this response. Several companies announce restructuring of their Canadian operations, with some sales positions eliminated but research facilities largely maintained.
Insurance Industry Adjustment: Private insurers face a significant business model disruption. Major providers like Sun Life and Manulife begin developing supplementary plans to cover medications not included in the initial formulary and additional services like preferred pharmacy access. Several insurers announce workforce reductions in their pharmaceutical benefits divisions.
Employment Transitions: The government establishes a $120 million Pharmacare Workforce Adjustment Fund to support retraining and transition assistance for insurance and pharmaceutical industry workers affected by the changes. Approximately 4,200 workers access these programs in the first year.
Pharmacy Sector: Community pharmacies express concerns about potential revenue losses from reduced dispensing fees and markups. The government responds by including enhanced medication management services in the program, creating new revenue streams for pharmacists providing patient education and monitoring.
Initial Costs: The program's first-year costs exceed projections by approximately 18%, primarily due to higher-than-expected enrollment and IT implementation challenges. This creates political vulnerability, with Conservative critics highlighting the overruns as evidence of poor planning.

Public Response and Utilization

The program's launch reveals significant pent-up demand:

Enrollment Surge: When the program launches on July 1, 2019, enrollment exceeds projections by 40% in the first month. Particularly high uptake occurs among self-employed individuals, part-time workers, and those in precarious employment without benefits.
Medication Adherence: Early data shows significant improvements in medication adherence, especially for chronic conditions like diabetes, hypertension, and asthma. Emergency room visits for complications of these conditions begin to decline within the first six months.
Regional Disparities: Despite the national program, utilization patterns reveal persistent regional disparities, with rural and remote communities showing lower uptake due to ongoing issues with pharmacy access and physician shortages.
Public Opinion: Public support for the program starts at 65% upon implementation but rises to 74% by December 2019 as people experience the benefits directly. Support is strongest among seniors, families with children, and those with chronic conditions.
Implementation Challenges: The program experiences several technical glitches in its first months, including system outages and processing delays. These receive significant media coverage, though most issues are resolved by fall 2019. Wait times at pharmacies temporarily increase during the transition period, creating frustration among some users.

Political Landscape Shift

The pharmacare implementation significantly reshapes the political environment:

2019 Election Impact: As the October 2019 federal election approaches, pharmacare becomes a central issue. The Liberals campaign on their implementation of the program and promise to accelerate the timeline for comprehensive coverage. The Conservatives shift from opposition to promising to maintain the program while improving its efficiency. The NDP advocates for faster expansion of the formulary.
Electoral Outcome: The Liberals win a narrow majority government (172 seats), performing better than in our timeline, particularly in urban ridings with many precarious workers and in seniors-heavy ridings. Exit polls indicate that pharmacare was a decisive issue for approximately 15% of voters.
Provincial Politics: Several provincial governments that initially opposed the program begin taking credit for its benefits, demonstrating the political popularity of pharmacare. Ontario Premier Doug Ford, initially a critic, becomes a supporter after seeing positive polling on the issue.
Healthcare Advocacy Evolution: Healthcare advocacy organizations that had long focused on pharmacare shift their attention to other gaps in the system, particularly dental care and mental health services, building on the pharmacare momentum.
International Attention: Canada's implementation of national pharmacare attracts significant international attention, particularly from the United States, where healthcare reform remains contentious. Several Democratic presidential candidates cite the Canadian program in their 2020 campaign platforms.

By early 2020, as the COVID-19 pandemic emerges, the essential medicines component of the Canadian Prescription Drug Plan is fully operational, covering approximately 80% of prescriptions. The government has announced an accelerated timeline for comprehensive coverage, now scheduled for July 2021 rather than January 2022. The program has become a central feature of Canadian healthcare, with high utilization and growing public support despite the implementation challenges and higher-than-projected initial costs.

Long-term Impact

Healthcare System Transformation

By 2025, the Canadian Prescription Drug Plan has fundamentally transformed the healthcare landscape:

Universal Coverage: The program has expanded to comprehensive coverage, with the national formulary now including over 4,500 medications. Coverage is truly universal, with 99.7% of Canadians enrolled either directly or through coordinated provincial programs in Quebec.
Integration with Medicare: Pharmacare has become fully integrated with the broader Medicare system. Electronic health records now seamlessly connect prescribing physicians, pharmacists, and other healthcare providers, improving coordination of care and reducing adverse drug events by 32% compared to 2018 levels.
Prescribing Patterns: Physician prescribing patterns have evolved significantly. The evidence-based national formulary and associated prescribing guidelines have reduced inappropriate prescribing, particularly of opioids (down 41%), benzodiazepines (down 38%), and unnecessary antibiotics (down 29%).
Pharmacy Practice Evolution: The role of pharmacists has expanded substantially. Most provinces now authorize pharmacists to prescribe for minor ailments and modify existing prescriptions, with these services covered under the CPDP. Community pharmacies have transformed into healthcare hubs, particularly in underserved communities.
Health Human Resources: The healthcare workforce has adapted to the new system. Universities have expanded clinical pharmacology programs, and a new specialty in pharmaceutical public health has emerged. Approximately 3,800 professionals now work directly in pharmacare administration and drug policy at federal and provincial levels.

Economic and Fiscal Impacts

The economic implications have evolved in sometimes unexpected ways:

System Costs: After the higher-than-projected initial costs, the program achieved stability by 2022. By 2025, the net annual cost to governments is $7.2 billion more than pre-pharmacare spending, but this is approximately $4.8 billion less than projected under the previous patchwork system—representing significant savings despite expanded coverage.
Pharmaceutical Industry Adaptation: The pharmaceutical landscape in Canada has transformed. While some multinational companies reduced their Canadian presence, others adapted to the new reality. Canadian generic manufacturers expanded significantly, and several innovative Canadian biotech firms emerged, focusing on areas prioritized in the national formulary.
Insurance Industry Transformation: Private insurers have successfully pivoted to offering supplementary coverage for non-formulary drugs, faster access to new medications before formulary decisions, and integrated health benefit packages combining drug coverage with dental, vision, and paramedical services not covered by Medicare.
Employer Benefits: Employers have redirected approximately 60% of their former drug plan spending to other benefits or compensation, with the remainder contributing to improved corporate profitability and competitiveness. Small businesses report significant advantages in recruitment and retention now that they can compete with larger employers without providing costly drug plans.
Broader Economic Effects: The program has produced measurable macroeconomic benefits. Labor mobility has increased by 7% as "job lock" (staying in a position solely for benefits) has decreased. Entrepreneurship rates have risen, with new business formations by individuals with chronic health conditions increasing by 18% compared to pre-pharmacare levels.

Public Health Outcomes

The health impacts have become increasingly evident:

Chronic Disease Management: Management of chronic conditions has improved substantially. Hospital admissions for complications of diabetes have decreased by 42%, for hypertension by 37%, and for asthma by 50%. These improvements are most pronounced among lower-income Canadians who previously had inadequate coverage.
Mental Health: Access to psychiatric medications has improved significantly, with consistent coverage eliminating previous barriers. Continuity of care for serious mental illnesses has improved, with 68% fewer treatment interruptions due to cost concerns. Emergency department visits for mental health crises have declined by 23%.
Health Equity: The program has reduced health disparities. The gap in medication adherence rates between the highest and lowest income quintiles has narrowed by 74%. Indigenous communities report 89% improvement in access to essential medications, though challenges persist in remote locations.
Life Expectancy Impact: Early epidemiological studies suggest a modest but measurable impact on life expectancy, with preliminary data indicating a potential gain of 0.4 years on average, with greater gains (up to 0.9 years) among lower-income populations.
Pandemic Response: During the COVID-19 pandemic, the pharmacare infrastructure proved unexpectedly valuable. The national formulary mechanism allowed for rapid, coordinated addition of COVID-19 treatments, while the unified data system provided real-time information on medication utilization patterns and shortages.

Political and Social Evolution

The political and social implications have been far-reaching:

Healthcare Federalism: The successful implementation of pharmacare has reshaped federal-provincial relations in healthcare. The collaborative model developed for pharmacare has been extended to new initiatives in mental health and home care, creating a more functional approach to healthcare federalism than the often-contentious relationships of the past.
Political Realignment: Pharmacare has contributed to a political realignment on healthcare issues. The program's popularity has made universal coverage a consensus position across the political spectrum, with debates now focusing on implementation details rather than the fundamental approach. This has pushed all major parties toward more comprehensive healthcare positions.
Public Expectations: The successful implementation of pharmacare has raised public expectations for addressing other gaps in Canadian healthcare. Dental care has emerged as the next major advocacy focus, with significant public support for some form of universal coverage, particularly for children and seniors.
Canadian Identity: Universal pharmacare has been incorporated into Canadians' sense of national identity, joining Medicare as a defining social program that distinguishes Canada from the United States. Public support for the program has stabilized at approximately 82%, with strong support across all regions and demographic groups.
International Influence: Canada's pharmacare model has influenced policy development internationally. Australia implemented a reformed pharmaceutical benefits scheme based partly on the Canadian model, and several U.S. states have developed programs inspired by the Canadian approach, despite federal inaction.

Pharmaceutical Innovation and Regulation

The system has driven significant changes in pharmaceutical policy:

Price Negotiations: The Canadian Drug Agency has established itself as an effective negotiator, achieving average price reductions of 23% compared to pre-pharmacare levels. The consolidated purchasing power has given Canada leverage similar to larger European countries, despite its smaller population.
Research Priorities: Research priorities have shifted toward areas of public health importance rather than market potential alone. The government established a $450 million Strategic Pharmaceutical Innovation Fund that has supported development of new antibiotics, treatments for rare diseases, and medications for pediatric conditions.
Approval Processes: Health Canada has reformed its drug approval processes, creating accelerated pathways for high-priority medications while maintaining safety standards. The time from global availability to Canadian approval for breakthrough drugs has decreased by 40%.
Transparency Initiatives: Canada has become a global leader in pharmaceutical transparency. All clinical trial data for approved medications must be publicly available, and the actual prices paid by the CPDP (after confidential discounts) are published annually, breaking with the previous norm of secrecy in pharmaceutical pricing.
Orphan Drug Framework: A comprehensive framework for rare disease medications was implemented in 2023, including specialized assessment processes, outcomes-based reimbursement agreements, and international collaboration on clinical trials. This has increased the number of available treatments for rare conditions by 62% compared to 2018.

Unexpected Developments

Several unforeseen consequences have emerged:

Cross-Border Dynamics: The price differential between Canadian and U.S. prescription drugs has widened further, leading to increased interest in cross-border shopping from American consumers. This has prompted diplomatic tensions and legislative responses on both sides of the border.
Digital Health Acceleration: The digital infrastructure developed for pharmacare has accelerated Canada's broader digital health transformation. The secure patient identity system created for the CPDP has been expanded to support virtual care platforms, patient portals, and interoperable health records.
Indigenous Health Sovereignty: Several First Nations have used the pharmacare implementation as an opportunity to assert greater control over their healthcare systems. The Nishnawbe Aski Nation in Northern Ontario now administers its own pharmaceutical program with federal funding but independent formulary decisions that incorporate traditional medicines.
Pharmaceutical Manufacturing: Concerns about drug shortages and supply chain vulnerabilities, highlighted during the COVID-19 pandemic, led to a renaissance in Canadian pharmaceutical manufacturing. By 2025, domestic production capacity for essential medicines has increased by 215% compared to 2018 levels.
Environmental Pharmacy: An unexpected environmental benefit has emerged from the program's medication return requirements. All pharmacies must accept unused medications for proper disposal, with costs covered by the CPDP. This has reduced pharmaceutical contamination in waterways by an estimated 47% since 2018.

By 2025, the Canadian Prescription Drug Plan has become a cornerstone of the healthcare system, as fundamental as Medicare itself. What began as a politically risky initiative has transformed into a defining national program with broad support across the political spectrum. The implementation challenges and initial costs have been largely forgotten, replaced by recognition of the health benefits, economic advantages, and contribution to Canadian social cohesion. The program stands as an example of how decisive policy action can overcome decades of inertia to address a significant public need.

Expert Opinions

Dr. Danielle Martin, Professor of Health Policy at the University of Toronto and former Chair of Canadian Doctors for Medicare, observes:

"The implementation of national pharmacare represents the most significant evolution of Canadian healthcare since the original Medicare program. What's particularly striking is how it has shifted our understanding of what's possible in Canadian health policy. Before 2018, there was a pervasive sense that major healthcare reform was too difficult given fiscal constraints and federal-provincial dynamics. The successful implementation of pharmacare—despite the inevitable challenges—demonstrated that transformative change remains possible in Canadian healthcare. This has had ripple effects beyond prescription drugs, creating new momentum for addressing other gaps in the system. The key insight from this experience is that incremental approaches to fundamental healthcare challenges often fail not because they're more practical, but because they don't generate the political will and public engagement necessary to overcome entrenched interests. The comprehensive approach to pharmacare created a clear public benefit that built its own constituency of support. This lesson is now informing approaches to other healthcare challenges, from mental health to long-term care, where bold rather than incremental solutions are increasingly seen as both necessary and possible."

Dr. Marc-André Gagnon, Professor of Public Policy at Carleton University and pharmaceutical policy expert, notes:

"The pharmacare implementation revealed something fascinating about pharmaceutical markets: they can be restructured more successfully than many economists predicted. The catastrophic scenarios forecast by industry—drug shortages, delayed launches, research exodus—largely failed to materialize. Instead, we saw a market adaptation that ultimately improved both efficiency and innovation focus. The consolidated purchasing power created by the single-payer model delivered price reductions that individual private plans could never achieve, while the transparent, evidence-based formulary process redirected innovation toward genuine therapeutic advances rather than minor modifications of existing products. Perhaps most importantly, the program demonstrated that pharmaceutical policy can prioritize public health while maintaining a viable market. The strategic reinvestment of a portion of the savings into targeted innovation funds has been particularly effective, supporting development in neglected areas like antimicrobial resistance and pediatric formulations. This suggests a path forward for other countries struggling with pharmaceutical access and affordability: the choice is not between innovation and access, but rather between a market structured around private interests and one structured around public health priorities."

Dr. Ruth Lopert, former pharmaceutical policy advisor to the Australian government and visiting professor at George Washington University, comments:

"Canada's pharmacare implementation offers important lessons for international pharmaceutical policy. The program successfully navigated the tension between immediate access and long-term sustainability by adopting a staged approach—beginning with essential medicines while building the infrastructure for comprehensive coverage. This avoided the 'all or nothing' dynamic that has stalled reform in other countries, particularly the United States. Equally important was the program's emphasis on evidence-based assessment while maintaining a patient-centered perspective. The inclusion of patient representatives in formulary committees and the development of clear, transparent criteria for coverage decisions helped build public trust in the system. The international impact has been significant, with several countries adopting elements of the Canadian approach, particularly the structured patient engagement processes and innovative agreements for high-cost medications. Perhaps most notably, Canada has demonstrated that a country can transition from a fragmented, inequitable system to universal coverage without the sky falling—an important precedent for nations still debating whether such transformation is possible. The Canadian experience suggests that while the details of implementation must be tailored to each country's context, the fundamental principles of universal access, evidence-based assessment, and consolidated negotiating power are broadly applicable."