The Act Respecting Pharmacare, which was introduced in Parliament recently as Bill C-64, represents a major milestone with the potential to transform the lives of Canadians from coast to coast to coast.

Providing Canadians access to medication as part of universal health care has been a battle for more than 60 years. But with the proposed legislation containing a mere 11 provisions, a lot of the key details of the new national pharmacare program are still to be determined.

To begin, it’s by no means certain that the provinces and territories will agree to take part because several of them appear increasingly loathe to accept federal incursions into what they see as part of their health-care turf.

If they do come on board, Bill C-64 foresees the provision of “universal, single-payer, first-dollar coverage” for “specific prescription drugs and related products intended for contraception or the treatment of diabetes.” It’s hard to imagine two more important types of medicines to pilot test a system of national pharmacare.

While the politics of jurisdictional turf plays out, the federal minister of health has one year to “request” that the newly formed Canadian Drug Agency develop both a national bulk-purchasing strategy and a list of essential prescription drugs. There’s nothing to stop the minister from making the same requests right now before Bill C-64 becomes law.

In any event, only when those two elements are in place — and assuming provinces and territories opt to participate — will single-payer, universal pharmacare for all essential medicines start to become a reality.

Integrity is key in forming the expert committee

With so much left open within the four corners of Bill C-64, there is a significant risk that pharmacare’s implementation will be plagued by inaction. Fortunately, the last section of the act may help guard against the risk of delayed implementation.

Under Section 11, the minister must “establish a committee of experts,” to produce a set of recommendations for the “operation and financing of national, universal, single payer pharmacare.”

If Parliament passes Bill C-64, the critical decisions that follow – how soon it becomes operational, what it encompasses and how its costs are paid — will depend in significant part on this committee. It is therefore critical to ensure that the committee is composed of people with demonstrated expertise in pharmaceutical policy and, even more importantly, that they are free from conflicts of interest.

The intersection of medicine and pharmaceuticals is rife with such conflicts, which exist whenever a secondary interest, such as research funding from a pharmaceutical company, may unduly influence a primary interest – for example, a physician’s decision about which medication to prescribe to a patient.

Dozens of studies show that even a small gift, such as a free lunch from a pharmaceutical sales rep, can alter a doctor’s prescribing decisions. In some instances, researchers with conflicts of interest have manipulated the evidence of a drug’s safety or effectiveness, minimizing the risks and overselling the benefits of a new therapy.

In the context of Canadian pharmaceutical policy, conflicts have shaped patient advocacy in favour of access to expensive therapies no matter the cost, or alternatively, undermined efforts to improve the affordability of medicines.

Look no further than 2023 and events surrounding reforms to the Patented Medicine Prices Review Board, Canada’s drug pricing regulator. As a former member of the board, I saw first-hand how that process was influenced and controlled by the pharmaceutical industry and its many surrogate organizations, including industry-funded patient groups — to the detriment of making medicines more affordable.

Ultimately, under industry pressure, the federal minister of health made the unprecedented move of calling on the arm’s-length body to suspend its consultation process.

The public interest first

With pharmacare now closer than ever before, we must not turn a blind eye to the insidious effects of conflicts of interest. On the contrary, if the purpose of Bill C-64’s committee is to provide evidence-based, unbiased recommendations about how to operationalize pharmacare in Canada, then steps must be taken to ensure this vital committee is free of such conflicts.

That doesn’t mean that the experts chosen to serve can’t have specialized perspectives and experiences that may contribute to the committee’s work. Having an interest in a policy issue doesn’t always amount to having a conflict.

But, having a financial stake in the policy issue at hand does because that kind of conflict usually skews the outcome in favour of the financial interest involved.

For example, a person who makes a living providing consulting services to provincial governments around drug benefit programs is not fit to offer advice about how to implement national pharmacare. They have a direct financial interest in preserving provincial control over which drugs should be publicly funded, compromising their ability to provide independent, evidence-based opinions about the scope of pharmacare.

By the same logic, physicians, economists, patient representatives and other experts whose work has been funded by the pharmaceutical or insurance industries have conflicts of interest that should disqualify them from committee membership. Why? Because just as financial conflicts can shape doctors’ prescribing decisions, research funding relationships are apt to shape experts’ thinking about how to finance pharmacare.

If and when Bill C-64 is enacted, the federal health minister may use the disclosure of a conflict of interest as a means to allow experts with financial relationships to sit on the committee. Disclosure of conflicts of interest has indeed become common practice in the world of medicine, pharmaceutical research and policy.

In this case, though, the stakes are too high: conflicts of interest must be avoided altogether.

The members of the committee of experts envisioned in Bill C-64 have decisions to make which must not be shaped by any interest other than the public benefit of national pharmacare. There is no risk of the industry not being heard in the process: the pharmaceutical and insurance industries will deploy vast resources in the weeks and months ahead to lobby against the legislation.

The government must put in place a firewall between those interests and the expert committee. Otherwise, Bill C-64 may amount to yet another dead letter in the long fight for access to affordable, essential medicines for all Canadians.

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Matthew Herder
Matthew Herder is the director of the Health Justice Institute and a professor of law and medicine at Dalhousie University. He holds a chair in applied public health from the Canadian Institutes of Health Research and the Public Health Agency of Canada. X: @cmrherder

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