The federal campaign trail can feel awfully provincial most days. The ghost of Doug Ford hangs over us like an election apparition, no matter how hard he tries to hide in the shadows.

At a recent event, Liberal Leader Justin Trudeau used Ford as a foil 14 times, invoking his image more often than that of his declared opponent, federal Conservative Leader Andrew Scheer. For his part, Scheer keeps name-dropping Kathleen Wynne, Ford’s equally unpopular predecessor as premier, to stoke antagonism.

Fighting phantom opponents may seem beside the point, but it actually points to a bigger problem in the campaign to date: It’s not just their rivals for the PM’s job who stand in their way now, but the premiers across Canada who may line up to block their path post-election.

Pharmacare is the biggest promise, and the thorniest problem, pitting Ottawa against the provinces. An ambitious plan for free prescription drugs underpins the platforms of the federal Liberals, New Democrats and Greens, and yet the proposal has especially weak support among the premiers — without whose co-operation Ottawa could not implement it.

Pharmacare remains the unfinished business of medicare, more than half a century after Ottawa and the provinces finally agreed to provide universal health coverage for all Canadians. Giving birth to medicare required major compromises among the politicians of the day, notably by deferring pharmacare to another day.

All these days and years later, we are no further ahead — in fact we are probably further behind, for the life-saving role of prescription drugs in fighting cancer, regulating blood pressure, controlling cholesterol levels, and modulating mental illness is far greater today than a half-century ago. Now we have free medicare without free medicine, undermining one of our proudest achievements.

It takes two levels of government to tango — or tangle. In 2017, Wynne’s government took the first steps toward a pharmacare program with OHIP+, providing free prescription drugs for young Ontarians up to age 24 while solidifying it for seniors.

Helping her drive the agenda was her then-health minister, Dr. Eric Hoskins, who was later hired by the federal government to help design a new national pharmacare program building upon Ontario’s initiative. But as Hoskins shifted to Ottawa, the legacy he left behind in Ontario unravelled with Wynne’s defeat in the 2018 Ontario election.

After ousting her from power, Ford moved swiftly to disembowel OHIP+, by gutting its universal coverage and restricting it to those without any plan at all. Canada’s biggest province was not only unplugging the universality of Wynne’s OHIP+ but shutting the door to any future pharmacare program nationwide.

Against that backdrop, Trudeau styles himself a counterpoint to Ford’s naysaying, promising voters he can restore pharmacare if they learn the lessons of last year’s election in this year’s campaign: “Unfortunately the choices people make really matter, as Ontarians are discovering,” he cautioned.

But Ontarians not only made that choice last year when they voted Ford into power, they also failed to make themselves heard when he axed OHIP+ days later. The event went unheralded and almost unnoticed.

Despite the preternatural pride of Canadians in medicare, there is shockingly little political interest in pharmacare today. Those who already have workplace benefits are content to pay (excessively) for them lest anyone tinker with what they already have; those who are jobless or retired, and thus dependent on government largesse through publicly-funded drug plans, are not clamouring for much more; and the young people who are experiencing precarious employment are not voting in sufficiently large numbers to apply political pressure.

It is a recipe for inertia, reminiscent of the political paralysis that Canadians find so confounding in the U.S. Just as many Americans resist giving up their private workplace health plans for so-called Obamacare mandated plans, so too Canadians are reluctant to risk any meddling with their existing private drug plans.

Interestingly, the imperative for pharmacare today is as much economical as ideological and social. Hoskins made the case — like many economists before him — that billions of dollars could be saved by replacing today’s patchwork system (notably the continuing gaps for millions who go uncovered and put their health at risk) with an efficient single-payer system that leverages universal coverage to maximize purchasing power with big pharmaceutical companies that currently overcharge us.

Ford is not alone among the premiers. Quebec’s François Legault has also spoken out against a national pharmacare program, insisting that his province’s share of any federal funding be rechanneled toward its existing “mandate” program (modelled on Obamacare, by which people choose their own private providers — thus fragmenting their collective purchasing power and diluting any single-payer efficiencies).

Now, Trudeau and the NDP’s Jagmeet Singh are on the campaign trail trying to persuade voters that there are enormous savings to be reaped from pharmacare, quite apart from the health benefits. But they face an uphill battle — not just from provincial resistance but voter indifference.

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Just over a year ago, Trudeau or Singh would have found a willing partner in Ontario, when Wynne was onside (and the provincial NDP had its own pharmacare plan). Today, Ford and most of his fellow premiers are at cross-purposes with such federal ambitions.

Which is why, barring another medicare miracle — and until voters find their voice — we may have missed the moment. All these years later.

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