We still haven’t figured out how to make health care truly universal
Earlier this month, the Advisory Council on the Implementation of National Pharmacare issued its final report on universal drug coverage.
Other countries such as the UK, Netherlands, Germany, Australia and New Zealand have universal health systems that also ensure a certain level of drug coverage available to its citizens. Canada is the only country that does not.
That means that everything from a doctor’s visit, to hospitalization, to blood work, to x-rays are covered — until the point that something is prescribed. At that point, Canadian coverage becomes spotty. There are provincial programs, but again, each is different in terms of everything from its eligibility criteria, to its subsidy structures. So at the end of the day, one in 10 Canadians say they cannot take their medications as prescribed, simply because they cannot afford them.
It is against this backdrop of obvious need that Council Chair Eric Hoskins released his report about national pharmacare. The question top of mind now is: is this report good policy or just politics?
Central purchasing power
The report itself advises a single-payer system of drug coverage. Standardized formularies, so everyone has fair access to the same coverage. Central purchasing of drugs, which would arguably drive down costs. Less administrative hassle and cost because there is only the one central drug agency. A similar system exists in New Zealand, which administers care through 20 district health boards that fall under its ministry of health.
While this sounds ideal in theory, the reality in your doctor’s office can be very different. Ontario tried — and failed — at a similar experiment with OHIP+.
OHIP+ was a program of universal single-payer drug coverage for those under 25. The plan positioned the province to become the first payer of a government-approved list of medications, many of which were older and cheaper than others in rotation. In order for patients to qualify for the newer — and often more effective — versions, they had to have tried and failed the generics. This led to many private insurers deciding to no longer pay for the cost of the drugs, because the government said it would eventually foot the bill if the patient was able to prove they needed them.
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The impact of this change was significant. Medications like Keppra, which had kept kids seizure-free and stable, were suddenly no longer covered by private insurers as of January 1, 2018. The same held true for some medications for depression, anxiety, rheumatoid arthritis and a number of other serious conditions. As a result, patients, parents and doctors found themselves jumping through hoops to try and find coverage. Otherwise, they were stuck swapping newer medications for older ones, risking side effects and ineffectiveness.
When the new provincial government was elected, Ontario switched to a gap-filling public-private mix: if a drug was already covered by private insurance, that coverage continued. Government top-up paid for alternatives that weren’t covered or for patients who had no private insurance. Similar systems exist in the Netherlands and Germany, both of which rely on private insurers to help cover the cost of medical care.
OHIP+ was one of the last campaign promises made by the Kathleen Wynne government. That clumsy legislation appeared to be engineered for political reasons, in an appeal for votes. But can the same be said of this pharmacare proposal?
Making big promises
At a time when support for the federal Liberals is flagging due to the SNC, Wilson-Raybould and Mark Norman scandals, voters should be wary of politicians who have a tendency to over-promise and under-deliver.
The authors of the federal pharmacare report cite the Canada Health Act (CHA) as the driving force for national pharmacare. The CHA advocates for health care that is publicly administered, accessible, comprehensive, universal and portable. But the reality is that this ideal varies greatly across and within provinces, leading some — including the Canadian Medical Association — to question whether the CHA has really been hitting the mark.
Many Canadians get good health care when they need it; many others have the exact opposite experience: health care characterized by long wait-times, lack of resources, doctor and nursing shortages, hallway medicine, burnout, and so on. This pattern of evidence suggests that before trying to tackle the necessary challenge that is pharmacare, it is even more essential to improve and modernize the CHA so that patients receive the care they deserve and need.
As a public policy, the key to national pharmacare will be integration, as evidenced by other countries with a universal health care system. The reality is that Canada isn’t one national health care system. Canada is more like a patchwork of different provincial health care systems that have different private-public mixes.
Consider who pays for medical care. Now consider who pays for all else that health care requires: physiotherapy, psychotherapy/counselling, occupational therapy, home care and long-term care, as well as prescription medications. The province pays for the former, you and I pay for the latter. Without integration into a truly universal system, pharmacare will become another Band-Aid solution.
While this report is only a series of recommendations, it provides the government a blueprint for a campaign strategy that will court the progressive voter. Given his recent struggles, it would not come as a surprise if, on the campaign trail, Prime Minister Justin Trudeau contradicts his own finance minister about fiscal responsibility when thinking about a pharmacare plan. In a rush to shore up his base, the prime minister is relying on Hoskins — the architect of the now-collapsed OHIP+ program — for his political future.
By ignoring mistakes of the past, this report appears idealistic and short-sighted. It is not the practical, long-term plan that our country needs to achieve true universal care. For that, this country needs a larger conversation about what we want from our health care system, and how much we are willing to pay for it.
Adam Kassam is a Physical Medicine & Rehabilitation specialist physician who was born and raised in Toronto, Ontario. Adam received an undergraduate education from Cornell University , an MD from Dartmouth Medical School and a Master’s in Public Health from Columbia University.
Nadia Alam is a family doctor and anesthetist in Georgetown, Ontario and a current Master’s candidate in Health Economics, Policy and Management at the London School of Economics. She is also the past President of the Ontario Medical Association.
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