A Public Matter? : An Ethical Analysis of the Canadian Pharmacare Public Policy Debate, 1997-2019

Background: Canada lacks universal pharmaceutical coverage (pharmacare). Calls for the implementation of national pharmacare date back to the introduction of Canadian Medicare and have recently resurfaced on the federal health policy agenda. Although public policies raise ethical and political questions, to date there has been limited analysis of the normative rationales that underpin arguments in the Canadian pharmacare debate. Accordingly, the objective of this study was to examine how bioethics—as a practically-oriented, normative inquiry—could contribute to understanding and informing the contemporary pharmacare policy debate. Methods: I conducted a qualitative, empirical bioethics case study of the Canadian pharmacare public policy debate from 1997 to 2019. I used an adapted thematic analysis to characterize the main policy arguments in 72 policy documents and transcripts in terms of their underlying normative rationales. To inform my analysis and interpretation of the data, I drew on a theoretical framework of four philosophical accounts of the division of public and private responsibility in the organization, financing, and delivery of health insurance. Findings: The contemporary pharmacare policy debate has shifted from considering whether to determining how universal pharmaceutical coverage ought to be realized; three main forms of universal coverage have been considered: public single-payer, a ‘fill-in-the-gaps,’ multi-payer program that builds on the existing mix of public and private insurance, and catastrophic coverage. The three proposals appeal to distinct normative rationales and accounts of political responsibility vis-à-vis health and health insurance. In turn, they frame and justify the problems of access, costs, and appropriateness and their attendant policy solutions differently. Growing support for public single-payer pharmacare in the contemporary debate is justified in reference to more explicit appeals to its efficiency-promoting features in addition to its equity- and community-promoting ones. Conclusion: This study provides an understanding of how arguments in the Canadian pharmacare policy debate are justified normatively. It suggests that the pharmacare debate is a politically normative debate that will require adjudicating between distinct policy objectives. The analysis illustrates how normative policy analysis can help discern and reframe underlying normative disputes in public policy debates.

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