Brief submitted to the Standing Senate Committee on Social Affairs, Science and Technology September 2024 Submitted by the Association québécoise des pharmaciens propriétaires Brief on Bill C-64:

An Act Respecting Pharmacare

Brief concerning Bill C -64:

An Act Respecting Pharmacare Association québécoise des pharmaciens propriétaires 2 CONTENT S EXECUTIVE

SUMMARY ................................ ................................ ................................ .. 3 ABOUT THE AQPP ................................ ................................ ................................ ........ 4 Comments on the draft legislation ................................ ................................ ................. 5 1. Universal coverage applicable in Québec ................................ ................................ 5 2. Objectives of the Health Minister................................ ................................ ........... 7 2.1.

Accessibility of prescription drugs ................................ ................................ ........ 7 2.2. Affordable prescription drugs ................................ ................................ ............ 10 2.3. Appropriate use ................................ ................................ ............................... 11 2.4. Universal coverage ................................ ................................ ........................... 12 Conclusion ................................ ................................ ................................ ................ 14

Brief concerning Bill C -64:

An Act Respecting Pharmacare Association québécoise des pharmaciens propriétaires 3 EXECUTIVE

SUMMARY On February 29 of this year , the H onourable Mark Holland, Canada’s Minister of Health, introduced Bill C-64 in the House of Commons. It was then adopted by the House on June 3.1 The bill institutes the Act Respecting Pharmacare (hereinafter, the “Pharmacare Act”), which lays the foundations of the initial phase toward a plan for national universal prescription drug insurance in Canada (hereinafter, the “National Plan”).

It is important to point out that the Pharmacare Act emphasizes the Government of Canada’s intent to maintain collaborations with the provinces and territories in establishing this universal plan, and recognizes their role in the provision of healthcare. The Association québécoise des pharmaciens propriétaires (Québec’s association of owner- pharmacists, hereinafter, the “AQPP”) supports the Government of Canada in its aim of improving accessibility and affordability of prescription drugs and related products for all Canadians.

To that end, this brief addresses specific issues applicable to Québec and offers recommendations enabling achievement of the federal Health Minister’s objectives. Following are the aspects that the AQPP wishes to bring to your attention in this brief: • Québec already provides universal prescription drug insurance coverage . All residents of the province are required to enrol in a prescription drug insurance plan, whether public or private.

Th e public plan is accessible to anyone who does not benefit from private in surance, and the Québec Act Respecting Prescription Drug Insurance provides for minimum coverage for the cost of pharmaceutical services and medications. • The Québec model meets the objectives of the National Plan, promoting accessibility and affordability as well as optimum use of pharmaceutical products, and providing universal coverage for all residents.

The mixed public-private system in use in Québec not only enables achievement of those objectives; it also enhances the public plan in place. • The issue of access to medications experienced by a limited number of Quebecers is related not to their financial situation, but rather to a complex set of social factors, including cognitive and mental-health issues. The Québec prescription drug insurance plan, instituted in 1997, has proven its worth and offers benefits that exceed those that the National Plan potentially guarantees.

The AQPP’s view is that imposing the National Plan in Québec would be tantamount to turning the clock back nearly three decades, reducing prescription drug coverage and access to pharmacies, both of which are indispensable for the provision of medications and pharmaceutical services. Based on the considerations set out in this brief , the AQPP supports the Government of Québec in its efforts to opt out of the National Plan with full compensation. 1.

An Act Respecting Pharmacare, Bill C-64 (Adopted – June 3, 2024), 1st session, 44th Parliament. ( hereinafter, “ C- 64”).

Brief concerning Bill C -64:

An Act Respecting Pharmacare Association québécoise des pharmaciens propriétaires 4 ABOUT THE AQPP Community pharmacists, pre sent in every region of Qu ébec, are trusted professionals consulted by more than one million Quebecers every week. In addition , as entrepreneurs, owner-pharmacists represent a considerable economic force in the province, employing more than 45,000 people. This makes community pharmac ies one of the leading private -sector employers in Québec. The AQPP was constituted pursuant to the Professional Syndicates Act2 and has existed since 1970.

It represents all owner-pharmacists in Québec, including 1,893 pharmacies and 2,060 owner-pharmacists,3 regardless of whether they are affiliated with a commercial chain or banner. The AQPP’s mission is to study, defend and develop the economic, social, legal and professional interests of its members. To that end, it engages with various stakeholders in the health sector and in government, both federal and provincial. 2. Professional Syndicates Act , CQLR, c. S-40. 3. AQPP, internal data, March 1, 2024.

Brief concerning Bill C -64:

An Act Respecting Pharmacare Association québécoise des pharmaciens propriétaires 5 COMMENTS ON THE DRAFT LEGISLATION 1. Universal coverage applicable in Québec As noted in the report A Prescription for Canada: Achieving Pharmacare for All , Québec requires all its residents to enrol in a prescription drug insurance coverage plan. That requirement to be insured is specific to Québec and unique among the provinces and territories. Mandatory coverage came into being with the adoption of the Act Respecting Prescription Drug Insurance in 1996 and its coming into force in 1997.

All residents of Québec have thus been required to take out prescription drug insurance for nearly three decades now.4 The Act Respecting Prescription Drug Insurance instituted Québec’s basic prescription drug insurance plan (hereinafter referred to by its French abbreviation, “RGAM”).5 The RGAM makes it possible for all Quebecers to have reasonable and fair access to the medications required by their state of health.

To that end, basic coverage for the cost of pharmaceutical services and medications is provided.6 That coverage is provided by the Régie de l’assurance maladie du Québec (the provincial health insurance board; hereinafter, the “RAMQ”) or by group insurance providers or the administrators of private-sector employee benefit plans,7 in two stages: first, based on eligibility of persons residing in Québec, and then through provision of guaranteed coverage for the costs of pharmaceutical services and medications for all such eligible persons. 1.1.

Eligibility for Québec residents The RAMQ is a public plan that provides coverage for certain groups of people, including those aged 65 or older and persons or families who are eligible under a financial assistance program.8 The RAMQ also guarantees coverage for anyone not required to join a private prescription drug insurance plan.9 If a Québec resident does not fall into one of the categories of people to whom the RAMQ provides coverage, they are therefore eligible for a private coverage plan, which they are required to join.10 For example, a person who, because of their employment relationship, has access to a group insurance plan through their employer must become a member of that plan and is not eligible for the RAMQ insurance. 4.

Régie de l ’assurance maladie , “À propos de la RAMQ ”, online: <Historique | Régie de l ’assurance maladie du Québec (RAMQ) (gouv.qc.ca) > ( viewed on March 19, 2024 ); Government of Canada, A Prescription for Canada: Achieving Pharmacare for All – Final Report of the Advisory Council on the Implementation of National Pharmacare (2019), p. 38 -39, online: <https://www.canada.ca/en/health-canada/corporate/about -health-canada/public - engagement/external-advisory-bodies/implementation -national-pharmacare/final -report.html > (viewed on March 19, 2024). 5.

Act Respecting Prescription Drug Insurance, CQLR, 2002, c. A -29.01 ( hereinafter referred to by its French acronym, “LAMED”),

Sec. 1. 6. Ibid.,

Sec. 2. 7. Ibid.,

Sec. 3 8. Ibid.,

Sec. 15(1) and 15(2). 9. Ibid.,

Sec. 15(4). 10. Ibid.,

Sec. 16.

Brief concerning Bill C -64:

An Act Respecting Pharmacare Association québécoise des pharmaciens propriétaires 6 That said, the RGAM excludes some classes of people who are covered under other plans, for example, the Federal Health Partnership, with which the AQPP, incidentally, has an agreement to provide coverage similar to that of the RGAM.11 1.2. Coverage under the basic plan Eligible persons, whether their coverage is provided under public or a private plan, benefit from universal basic coverage; i.e., that of the RGAM.

That plan provides basic coverage for the cost of pharmaceutical services and medications to all persons eligible for it.12 The RGAM establishes, by regulation, a list of drugs and supplies (hereinafter, the “RAMQ List”) that must be included in coverage, whether public or private. This list is currently the most exhaustive and complete in Canada.

Several classes of medications are on the RAMQ List, namely, those covered without conditions and those referred to as exceptional medications, which are covered according to certain therapeutic indications.13 In addition, in some cases a non-listed drug or an exceptional drug for a different therapeutic indication may be covered, pursuant to the exception patient program.

This measure allows for coverage of the drug cost where the insured person demonstrates a specific and exceptional need.14 It is also important to note that Québec manages a number of programs allowing for access to prescription drugs at no charge ; for example, free universal access to voluntary medical termination of pregnancy (the abortion pill).15 In addition to the preparation and dispensing of prescriptions, the RGAM covers a number of pharmaceutical services that must be insured under both the RAMQ and the private plans; for example, extension of a prescription by a pharmacist.16 Note that patients are not required to spend any money out of pocket to obtain these services, because they are exempt from application of any deductible or coinsurance.

The RGAM also sets a contribution maximum for insured persons, whether coverage is provided by a privat e plan or the public plan: the maximum contribution amount for a reference period of one year is $1,196 per adult (including the deductible amount).17 It also limits the proportion of coinsurance that can be borne by the insured person to 33% of the cost of pharmaceutical services and medication s.18 In certain situations, not ably those 11. Ibid.,

Sec. 6. 12. Ibid.,

Sec. 2, 7 and 8. 13. Ibid.,

Sec. 8 and 60; Regulation Respecting the List of Medications Covered by the Basic Prescription Drug Insurance Plan, CQLR, c. A-29.02, r. 3 ; Régie de l ’assurance maladie , List of medications (2024), online: <List of medications, March 6, 2024 | Régie de l ’assurance maladie du Québec (RAMQ) (gouv.qc.ca) > (viewed on March 19, 2024). 14. Régie de l’assurance maladie , “Médicaments d’exception et Patient d ’exception,” online: <Patient d’exception | RAMQ (gouv.qc.ca)> (viewed on March 19, 2024). 15.

Régie de l ’assurance maladie , “Programs for free access to medications, supplies and services, ” online: <Programs for free access to medications, supplies and services | Régie de l ’assurance maladie du Québec (RAMQ) (gouv.qc.ca)> (viewed on March 19, 2024). 16. LAMED,

Sec. 8 and 78; Regulation Respecting the Basic Prescription Drug Insurance Plan , CQLR, c. A-29.01, r. 4,

Sec. 1.1; Health Insurance Act , CQLR, c. A-29,

Sec. 19. 17. LAMED,

Sec. 13. 18. Ibid.,

Sec. 12.

Brief concerning Bill C -64:

An Act Respecting Pharmacare Association québécoise des pharmaciens propriétaires 7 involving low-income persons insured by the RAMQ, the insured’s contribution may be reduced to zero.19 The RGAM thus provides basic coverage for all eligible p ersons, who comprise Québec residents, with some exceptions. 2. Objectives of the Health Minister

Section 4 of the Pharmacare Act sets out the principles that the Minister is to consider in continuing to work toward the implementation of the National Plan. From these principles, it is possible to infer the objectives pursued by the le gislator in developing the National Plan. There are four: 1) Improve the accessibility of pharmaceutical products; 2) Improve the affordability of pharmaceutical products; 3) Support the appropriate use of pharmaceutical products; and 4) Provide universal coverage across Canada.20 The AQPP submits that Québec, by means of the RGAM, already fulfils those objectives. 2.1. Accessibility of prescription drugs

An Act Respecting Pharmacare 4. The Minister is to consider the following principles and the Canada Health Act when collaborating with provinces, territories, Indigenous peoples and other partners and stakeholders with the aim of continuing to work toward the implementation of national universal pharmacare : [. . .]

a) improve the accessibility of pharmaceutical products, including through their coverage, in a manner that is more consistent across Canada; (emphasis ours) The first objective of the National Plan is to provide for universal access to prescription drugs across Canada. As outlined in the preceding section, this objective has been achieved, and indeed surpassed, by the RGAM, under which coverage for prescription medications is provided for all residents of the province. It is important to note that this coverage has been developed over a span of more than three decades and is the most exhaustive in Canada.

Québec’s prescription drug coverage is reliable and offers significant guarantees to all residents. Moreover, if the federal government were to impose application of the National Plan in Québec, access to medications would be jeopardized. First of all, accessibility of medications in Québec is enhanced by the mixed system that the province has established; that is, coexistence of public and private regimes. The RAMQ’s Annual Report for 2022-2023 states that 3.9 million people in Québec are covered under the public prescription drug insurance plan.

Given the requirement to be insured in Québec, this means that another 4.5 million residents are insured under a private plan.21 The private plans 19. Ibid.,

Sec. 29. 20. C-64,

Sec. 4. 21. Régie de l’assurance maladie , “La RAMQ en quelques chiffres ”, online: <La RAMQ en quelques chiffres | Régie de l’assurance maladie du Québec (RAMQ) (gouv.qc.ca) > (viewed on March 19, 2024 ).

Brief concerning Bill C -64:

An Act Respecting Pharmacare Association québécoise des pharmaciens propriétaires 8 therefore play an important role in ensuring prescription drug accessibility. Designing a single- payer National Plan in Québec would be counterproductive and contrary to the objective of improving accessibility of prescription drugs. The National Plan would provide coverage only for certain “essential prescription drugs and related products.”22 Private plans currently cover medications that are not on the RAMQ List, which ensures coverage that extends beyond that guaranteed by the RGAM.

In 2019, the AQPP tasked economist Yanick Labrie with analyzing the impact of various prescription drug insurance reform scenarios in Canada. His report (hereinafter, the “Research Report”) stated that slightly more than 5% of claims submitted to private plans concern medications that are not covered by the RAMQ.23 Furthermore, if the federal government were to impose application of the National Plan in Québec, the viability of private insurance plans would be greatly threatened.

The notion that private plans could continue to offer coverage for drugs not covered by the National Plan is unrealistic: the private insurers would be able to offer coverage for only a limited number of drugs, which tend to be among the most expensive.

That market share would not be sufficient to ensure the profitability of the private insurers’ insurance plans.24 Absent such private-plan coverage, Québec residents would therefore have to pay out of pocket for medications that are not on the National Plan formulary, discontinue using those medications, or change medications.25 Some insured persons would also lose their existing coverage and see it replaced by less generous coverage. Lastly, it must not be forgotten that community pharmacies are key to ensuring accessibility of prescription drugs.

Community pharmacies also provide pharmaceutical services that extend beyond mere dispensing of medications. These pharmacies must be accessible, otherwise residents will not be able to obtain their medications and the many services that pharmacists provide to the population. In Québec, there are nearly 1,900 pharmacies offering neighbourhood services all across the province.26 At present, there is a considerable difference between the fees paid by private plans and those paid by public plans in Canada.

The fees covered by the RAMQ for prescription preparation and dispensing in Québec are determined by an agreement with the provincial health ministry, which establishes a fixed rate, regardless of the pharmacies’ actual preparation and dispensing costs. In the case of users covered by private plans, pharmacists can charge their customary prices.

This allows pharmacists to bill for the true cost of the service, depending on the complexity of the treatment and the scope of management required.27 Assuming that the National Plan adopts a fixed fee structure, there would be considerable impacts on the financial health of pharmacies. For example, if pharmacists’ fees for dispensing or renewing prescriptions for diabetes and birth control medications were the same as the 22. C-64,

Sec. 8(1). 23. Labrie, Yanick, Analyse d ’impact de divers scénarios de réforme à l ’assurance médicaments au Canada (2019) (hereinafter, the “Research Report ”), p. 22 and 23. 24. Ibid. 25. Ibid. 26. AQPP, internal data, March 1, 2024. 27. Research Report, p. 56.

Brief concerning Bill C -64:

An Act Respecting Pharmacare Association québécoise des pharmaciens propriétaires 9 rates set for RAMQ insureds, based on all of the medications available on the market, the estimated losses for Québec community pharmacies in 2023 would have been more than $73 million based on the rates in effect that year .28 Moreover, those impacts would be magnified if the fee reimbursements were lower than those stipulated for RAMQ insureds, as we witnessed recently in the case of the Public Service Health Care Plan (hereinafter, the “PSHCP”), as it applies outside Québec.

In that case, the PSHCP decided to unilaterally cap the dispensing fee coverage at $ 8 per service, leaving the excess to be borne by the user,29 and to cap the number of services per calendar year at five in the case of maintenance medications, in the process encroaching on the pharmacist’s professional judgment as to the duration of treatment and the quantity of medications that should be dispensed to each user .

In that case , the AQPP had to make representations in order to exclude Québec from application of those caps, so as to ensure respect for pharmacists’ professional judgment and limit drastic losses in revenue.

If it were decided, as part of the National Plan, to establish a national rate for the dispensing or renewal of prescriptions for diabetes and birth control medications—for example, a rate of $8 as was the case for the PSHCP —with no surplus billable to the user, this would result in losses to Québec pharmacies in excess of $84 million, based on the rates in effect in 2023.30 It is important to note that, with a view to promoting professional independence, Québec law regulates the income that pharmacies can earn from sales of medications, notably by limiting the amounts payable in professional allowances by drug manufacturers.

Those allowances are capped at 15% in Québec,

whereas they are not subject to any maximum in the other provinces. As a result, the majority of pharmacies’ funding is derived from the professional fees associated with the pharmaceutical services provided, including the prescription dispensing or renewal. 31 The Québec model leaves pharmacies particularly vulnerable to variations in the fees for the services they provide. The undermining of pharmacies’ financial health and those anticipated losses would have a direct impact on accessibility of prescription drugs.

The impacts of revenue losses could extend from reduced operating hours to the closing of certain pharmacies .32 By way of comparison, it is in structive to note the case of New Zealand, where the introduction of spending controls, in addition to a lowering of dispensing fees, led to the clos ing of 271 pharmacies between January 1998 and May 2014, despite a growing population.

Consequently, access to pharmaceutical services is considerably reduced and pharmacies have been compelled to reduce opening hours, for example by closing before 6 p.m. and closing on Sundays.33 The effects on access ibility of healthcare services in Québec could be 28. AQPP, internal data, March 20, 2024. The amount is calculated using statistical data for 2023. To determine the actual losses on the date the law comes into force, it would therefore have to be indexed. 29. Public Service Health Care Plan Administration Authority, ”Drug Benefit, ” online: <PSHCP | Drug Benefit > (viewed on April 4, 2024). 30.

AQPP, internal data, March 20. 2024. The amount is calculated using statistical data for 2023. To determine the actual losses on the date the law comes into force, it would therefore have to be indexed. 31. LAMED. 32. Research Report , p. 34-35. 33. Ibid., p. 45.

Brief concerning Bill C -64:

An Act Respecting Pharmacare Association québécoise des pharmaciens propriétaires 10 devastating, especially given that for some communities in regions, pharmacies are the only local access point for healthcare services. The financial health of pharmacies is not only a guarantee of accessible medication, but also of access to primary care for all Québec residents, notably for the management of chronic illnesses. 2.2. Affordable prescription drugs

An Act Respecting Pharmacare 4. The Minister is to consider the following principles and the Canada Health Act when collaborating with provinces, territories, Indigenous peoples and other partners and stakeholders with the aim of continuing to work toward the implementation of national universal pharmacare: [. . .]

b) Improve the affordability of pharmaceutical products, including by reducing financial barriers for Canadians ; (emphasis ours) The second objective of the National Plan is to make prescription drugs more affordable. This is founded on the premise that Canadians face numerous financial barriers to taking their medication as prescribed. 34 In Québec, multiple measures are already in place to ensure prescription drug affordability. One key to improving affordability of me dications is a proper framework for the insured person’s contribution.

Québec’s mixed system enables the lowering of out -of-pocket expenses by defining the maximum deductible amount, the coinsurance amount and the contribution that may be demanded of the insured.35 As regards the cost of medications, the pharmacist is required by law to sell a prescription drug covered by the RGAM to the insured person at the price that they themselves paid.36 The price of a medication or service sold by a manufacturer is established by the RAMQ List.

For a manufacturer to have a drug entered on the list, it must undertake to submit a guaranteed selling price for the duration of the list’s validity period.37 The price payable by the RGAM for a given medication is then established according to the lowest -price method (with some exceptions). This method determines the lowest price offered by a given manufacturer among all drugs with the same generic name, form and potency. The price reimbursed by the RGAM is therefore that of the manufacturer guaranteeing the lowest price.

If the insured prefers to obtain a medication with a higher selling price (for example, if they wish to obtain the original brand-name drug), they must pay the difference between the lowest price and the price of that preferred med ication.38 Manufacturers have an interest in guaranteeing a more attractive price so as to capture a larger market share and in turn prevent users having to pay 34. C-64,

Sec. 4b). 35. Research Report , p. 26. 36. LAMED,

Sec. 8.1.2 p. 1. 37. LAMED,

Sec. 60 p. 4; Regulation Respecting the Conditions Governing the Accreditation of Manufacturers and Wholesalers of Medications, CQLR, c. A-29.01, r.2; Regulation Respecting the List of Medications Covered by the Basic Prescription Drug Insurance Plan ; Régie de l’assurance maladie, List of medications. 38. Régie de l’assurance maladie , List of medications,

Sec. 1.2, 1.2.2 and 1.2.2.1.

Brief concerning Bill C -64:

An Act Respecting Pharmacare Association québécoise des pharmaciens propriétaires 11 uninsured surcharges. With respect to biologic drugs included on the RAMQ List, we note that under a recently implemented policy, the brand -name drug ceases to be covered when a biosimilar comes to market.39 When that policy was instituted, the Québec health ministry estimated the annual savings for the RAMQ and its insureds to be more than $100 million.40 Lastly, we note that in Québec, in addition to preparing and dispensing prescriptions, pharmacists provide many other professional services.

For instance, pharmacists can prescribe a course of treatment or extend a prescription. These services financed by the public plan or private plans are provided free of charge to Quebecers. The implementation of the National Plan raises a number of questions relative to those professional services. Since it has not been established that the National Plan will cover such services, who would pay for them? As established above, the survival of private insurers’ provision of prescription drug insurance is not certain.

If the private insurers were no longer p articipating in these drug insurance programs, would the RAMQ have to bear the cost of those fees for users who were previously covered under private plans? If so, we foresee major financing issues . 2.3. Appropriate use

An Act Respecting Pharmacare 4. The Minister is to consider the following principles and the Canada Health Act when collaborating with provinces, territories, Indigenous peoples and other partners and stakeholders with the aim of continuing to work toward the implementation of national universal pharmacare: [. . .]

c) Support the appropriate use of pharmaceutical products — namely, in a manner that prioritizes patient safety, optimizes health outcomes and reinforces health system sustainability — in order to improve the physical and mental health and well -being of Canadians; (emphasis ours) To further the implementation of the national universal pharmacare plan, the federal Health Minister invokes a third objective, that of supporting the appropriate use of pharmaceutical products so as to improve Canadians’ physical and mental health and well-being.

We regard this objective as having been achieved in Québec, on the one hand because of the role of the Institut national d’excellence en santé et en services sociaux (national institute for health and social services excellence; hereinafter, the “INESSS”), and on the other, by virtue of the ethical obligations incumbent on all pharmacists. First of all, in Québec, the INESSS evaluates all drug listing requests so that the cost of a drug can be covered by the RGAM, and makes recommendations to the provincial health minister 39. Ibid.,

Sec. 2. 40. Ministre de la santé et des services sociaux , “Le ministre Christian Dubé annonce un virage vers les médicaments biosimilaires ” (May 18, 2021), online: <https ://www.msss.gouv.qc.ca/ministere/salle -de - presse/communique-2864/> ( viewed on March 19, 2024 ).

Brief concerning Bill C -64:

An Act Respecting Pharmacare Association québécoise des pharmaciens propriétaires 12 regarding reimbursement of the drug’s cost via the basic plan coverage.41 In accordance with its mission to promote clinical excellence and the efficient use of resources in the health and social services sector,42 the INESSS makes its recommendations in consideration of the level of need of the persons affected by those recommendations, the ratio of the benefits for those persons to the cost to the health and social services system , and the foreseeable consequences of the recommendations on health and social services system resources.

From that perspective, the federal Health Minister’s objective of supporting the appropriate use of pharmaceutical products is fully achieved. Second, the AQPP calls the Standing Committee’s attention to a distinctive feature of Québec legislation whereby only pharmacists are entitled to be pharmacy owners.43 This exclusive property right guarantees not only pharmacists ’ professional independence, but also the quality of care and services provided to users .

In accordance with their ethics obligations, “[t]he primary duty of pharmacists is to protect and promote the health and well -being of their patients; they must help their patients reap all possible benefits from their medication therapy.”44 From that perspective, the AQPP submits that this exclusive property right provides for an additional control mechanism when it comes to the appropriate use of pharmaceutical products.

If a pharmacist fails to meet their obligations, they must go before the Ordre des pharmaciens du Québec Disciplinary Council and risk sanctions such as being struck off the roll of the Ordre, which would require them to sell their pharmacy. 2.4. Universal coverage

An Act Respecting Pharmacare 4. The Minister is to consider the following principles and the Canada Health Act when collaborating with provinces, territories, Indigenous peoples and other partners and stakeholders with the aim of continuing to work toward the implementation of national universal pharmacare : [. . .]

d) Provide universal coverage of pharmaceutical products across Canada. (emphasis ours) The final objective of the National Plan is to provide universal coverage of prescription drugs to all Canadians so that everyone enjoys the same protection.45 In spite of the social safety net introduced in Québec to ensure the accessibility, affordability and optimal use of medications as well as universal coverage, a very small percentage of the population does not enjoy those benefits, even though they have access to them.

This unfortunate reality is the result of complex social factors extending well beyond financial considerations. Research has shown that geographical barriers, disparities in education and 41. LAMED,

Sec. 60. 42. Act Respecting the Institut national d ’excellence en santé et en services sociaux , CQLR, c. I-13.03,

Sec. 4. 43. Pharmacy Act , CQLR, c. P-10,

Sec. 27. 44. Code of Ethics of Pharmacists, CQLR, P-10, r. 7,

Sec. 6. 45. C-64,

Sec. 4d).

Brief concerning Bill C -64:

An Act Respecting Pharmacare Association québécoise des pharmaciens propriétaires 13 systemic discrimination can hamper access to healthcare for certain groups. 46 These multidimensional factors require global, inclusive solutions guaranteeing equitable access to care for all. The primary problem, therefore, is not the financial aspect of drug accessibility, but rather the capacity of some people to follow their treatment as prescribed.

In the case of diabetic patients who do not take their medications as they should, cognitive and mental - health issues, the fear of side effects and a lack of understanding of the part of patients are greater determining factors than cost or type of insurer.47 With regard to birth control medications, certain issues have more to do with some young women’s fears that their parents, who have private insurance, may learn that they are taking the drug as a result of claims to the insurer. Those fears prevent some young women from accessing these products.

Thus the barrier to accessibility is not financial, and a public health program enabling young women to obtain birth control medication free of charge would be beneficial. Since the challenges faced by some people when it comes to their drug treatment are not financial, the universal coverage offered in Québec is functional, and the National plan would not offer any added value with respect to those challenges, as opposed to the implementation of public health programs.

Thus the National Plan objective of providing universal coverage has already been achieved by Québec and, as shown previously, if it were to be replaced by another single -payer universal plan, this would be to the detriment of millions of Québec residents and would restrict pharmacists ’ capacity to provide neighbourhood services and accessibility to prescription medications. 46. Scheen, André and Didier Giet, «Non-observance thérapeutique: causes, conséquences, solutions» (2010) 65 - (5-6) Revue médicale de Liège 239, online: <ORBi: Référence détaillée (uliege.be)> (viewed on September 11, 2024). 47.

Campbell, Rachel B ., Matthew L arsen, Anna D igiandomenico, Marleane A . Davidson, Gillian L . Booth et al., “ The challenges of managing diabetes while homeless: a qualitative study using photovoice methodology,” (2021) 193-30 Canadian Medical Association Journal 1184, online: <DOI: 10.1503/cmaj.202537> ( viewed on September 11, 2024).

Brief concerning Bill C -64:

An Act Respecting Pharmacare Association québécoise des pharmaciens propriétaires 14 CONCLUSION As explained in this brief, Québec already has universal prescription drug insurance coverage. All of its residents are required to enrol in a prescription drug insurance plan, either public or private. Moreover, the Québec model meets the objectives of the National Plan: it promotes accessibility and affordability as well as optimum use of pharmaceutical products, and provides universal coverage for all residents.

The mixed regime in use in Québec not only allows those objectives to be met; it also enhances the public plan in place. There are other social factors that may determine whether people opt for coverage under the RGAM, even though it is compulsory. Thus, if the government proceeds, it will be necessary to include at least two pharmacists on the expert advisory committee tasked with developing the new plan. These professionals will help ensure that the National Plan is developed with a clear understanding of on-the-ground realities.

That said, requiring Québec to sign on to the National Plan would be tantamount to turning the clock back nearly 30 years. Accessibility of prescription drugs would in fact be jeopardized because it is not certain that the private insurance plans would survive; this would have an impact not only on prescription drug coverage for users, but also on the financial health of the community pharmacies that enable accessibility of medications and pharmaceutical services. The impacts of revenue losses could be considerable, ranging from reduced opening hours to the closing of some pharmacies.

Lastly, we emphasize that, while the power to legislate in the area of health is a competency shared between the provinces and the federal government, it is undeniable that the provinces are empowered to legislate with regard to health insurance, in accordance with their exclusive jurisdiction over establishment.48 Indeed, that constitutional right is reflected in the

preamble of the Act Respecting Pharmacare: “[T]he Government of Canada recognizes the role of the provinces, territories and Indigenous peoples in the provision of healthcare [. . .].”49 In consideration of the foregoing, the AQPP supports the Government of Québec’s efforts to withdraw from the prescription drug insurance program with full compensation. 48. Brideau, Isabelle, Laurence B rosseau and Allison Lowenger, The Distribution of Legislative Powers : An Overview, Ottawa: Library of Parliament HillStudies, 2022, p. 10 -11, online: <The Distribution of Legislative Powers: An Overview> ( viewed on March 19, 2024 ). 49. C-64,

Preamble.