Despite Canadians’ pride in medicare and the values underpinning it, the system is conspicuously incomplete. Universal public health insurance in Canada ends as soon as a patient is handed a prescription to fill; yet prescription drugs are the second largest component of health system costs. We look back at key moments in Canadian healthcare history that shaped our pharmacare system – or lack thereof. We look forward to changes in demography and technology that will increase the need for pharmacare reform in the near future. We conclude that meaningful public engagement in pharmacare design may generate the clarity of goals and level of political support needed should windows of policy opportunity open again.