As the debate on reforming the drug insurance system intensifies, interest in a national pharmacare program is growing. What should it look like?

Proposals for reforming Canada’s public-private drug insurance system have been put forward by academics, politicians and patients over many years. With increased interest in a national pharmacare program expressed in the present federal government’s emphasis on “affordability, accessibility and appropriate use of prescription drugs” and its creation of the Advisory Council on the Implementation of National Pharmacare, the debate around what such a program should look like and how it should be financially supported has intensified.

When Canadians are asked about national pharmacare, they are almost always highly supportive, although probably this is because they envisage improved access to drugs at a lower cost. However, as a recent Nanos poll showed, only a third of Canadians think a federal program would spend tax dollars well, just 30 percent believe the government would do a good job at making the right decisions about which medicines can be prescribed, and less than a quarter think a federal-government-controlled program would be lean, without unnecessary paperwork.

The aim of some politicians, government officials and academics who are devoted to a totally public health care system is to achieve a national pharmacare program that would reduce the inequity they perceive in the existing provincial programs. By inequity, they are generally referring to the 11.3 percent of Canadians who either have no access to public or private drug insurance, or do not get the public insurance for which they are eligible because the deductibles or copayments are too high.

However, this is not the only inequity in the present drug plans. More and more drugs that can extend or significantly improve the quality of patients’ lives, but require continuing treatment that can cost hundreds of thousands of dollars each year, are becoming available. In general, unless patients receive these drugs without charge from the manufacturer, have particularly generous private insurance or are extremely wealthy, few can benefit from them, but this fact is commonly ignored.

Over 11 percent of Canadians either have no access to public or private drug insurance or do not get the public insurance for which they are eligible because the deductibles or copayments are too high.

The presentations and writings about many of these proposals are sprinkled with the words “equity,” “equitable” and “equality” — terms that are related but do not have the same meaning. “Equity” and “equitable” are about a fair and just system that provides medicines for everyone to benefit based on their need. “Equality” means treating everyone exactly the same way.

Greater equality could be realized within the present framework of provincial drug plans. These five steps would make significant improvements:

  • Change the drug plans for seniors and social assistance recipients in Ontario and the Atlantic provinces and the income-based drug plans of the western provinces into Quebec-style public-private systems. Despite cost-containment issues, Quebec has been largely successful in providing drug access.
  • Align the clinical criteria required to obtain reimbursement for many drugs so that they are consistent in all plans. For example, alendronate, a common drug used for osteoporosis, is reimbursed without restriction in seven provinces, but documentation of osteoporotic fractures or a risk of fractures is required in the other three before reimbursement can be received.
  • Eliminate the deductibles and copayments in Ontario and the Atlantic provinces for take-home cancer drugs for patients without private insurance, which can result in out-of-pocket costs of anywhere from $2,000 to more than $14,000. In the western provinces, no such payments are required.
  • Make public drug plans more progressive by reducing or eliminating deductibles and other charges for the least wealthy individuals and families, as British Columbia has done.
  • Instead of the existing “opt in” system, where unnecessary paperwork and complicated criteria make receiving drug coverage exceptionally difficult for people with challenges related to social determinants of health, literacy or other issues, change to an “opt out” program, where everyone is eligible unless they request exemption.

Other steps could also be undertaken to improve equality, but it is unlikely that all inequalities can be eliminated.

These five steps would be better than implementing the equalization approach espoused by some academics and the Ontario NDP, in which only 125 medicines would be deemed essential. This would be much worse than the current programs, especially when one considers that the World Health Organization’s Model List of Essential Medicines, which is mainly designed for and used by impoverished developing nations, has over 300 medicines, and the often-criticized Ontario drug plan provides coverage for more than 700 drugs.

Everyone being treated the same is always difficult to accomplish because, to paraphrase George Orwell, some individuals will always be more equal than others. The risk with a national pharmacare program focused solely on equality is that it could provide equal access to some drugs to all patients but could also deny access to other medicines to all patients.

A national pharmacare program based on equity instead of equality would not just cover a one-size-fits-all set of drugs. Rather, it would provide the medicine deemed appropriate by the health care provider and the patient for the patient’s specific condition or disease.

This type of program would provide coverage to patients who presently have none. It would also extend coverage to patients whose insurance, whether public or private, presently denies access due to a drug’s high cost or limits access by requiring the patient’s circumstances to match clinical criteria that are overly restrictive or, in some cases, make little clinical sense. An equitable program would satisfy unmet needs and should lead to the federal government’s desired objectives of improved accessibility and appropriate prescribing, and also to better health outcomes, which should be a primary goal of all Canadian governments.

What about affordability? This seems to be the real objective of the federal government, as demonstrated in its proposed changes to the regulations governing the Patented Medicine Prices Review Board. The PMPRB has ensured that Canadians do not pay excessive prices for patented drugs for 30 years. More recently, the pan-Canadian Pharmaceutical Alliance (pCPA), the organization that represents federal, provincial and territorial government drug plans, has been negotiating with pharmaceutical manufacturers to achieve price agreements that contain costs.

The pCPA claims to have saved Canadians almost $2 billion annually, but this is likely a theoretical amount based on negotiated price reductions for both brand-name and generic drugs. To achieve this “saving,” the pCPA costs Canadian taxpayers a significant amount of real money: $50 million from the federal government and at least $3 million from the provinces and territories over the past two years, for an office of just 10 people. It’s no surprise that Canadians doubt that a federal-government-controlled national pharmacare system would be cost-effective.

Only covering the cheapest drugs must not be the sole objective of a national pharmacare program. In fact, cost containment should not be its primary aim at all. The goal should be to ensure that the best medicines, based on a truly independent assessment of value, are made accessible without excessively restrictive or nonsensical clinical criteria so that patients receive the most appropriate medicine depending on their individual situation.

Many costly therapies that will benefit only highly specific types of patients are on the horizon. An equitable pharmacare program, whether organized nationally or provincially, will not be achieved if patients are denied access to these medicines that could improve or extend their lives — any more than if patients who cannot afford basic medicines are not helped.

Ideally, instead of rearranging the deck chairs on the Titanic of Canada’s current public drug insurance hodgepodge, the federal government should lead a major overhaul of the health care delivery system to allow Canadians to benefit from new major therapeutic advances in a timely manner, as well as existing medicines, without being faced with a choice between suffering or destitution.

Illustration: Shutterstock, by pogonici.


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