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One in four Canadians who do not have drug insurance are unable to afford to take their prescription drugs as directed, a new study shows.

And, over all, one in 10 Canadians struggle to pay for their drug treatments, even if the have public or/and private insurance, according to research published in Monday's edition of the Canadian Medical Association Journal.

That means, practically, that millions of patients fail to fill or refill prescriptions, or skip doses to cut costs.

"These levels of non-adherence are something to be concerned about," Michael Law, an assistant professor at the Centre for Health Services and Policy Research at the University of British Columbia, said in an interview.

"When people don't take their meds, there are, potentially, higher costs in other parts of the system," he said.

The findings are based on data from 5,732 respondents in Statistics Canada's Canadian Community Health Survey. The data show that 9.6 per cent of Canadians did not take a prescription as directed because of the cost. That included 26.5 per cent of those without health insurance reporting not being able to afford their prescription drugs.

According to Statscan, 82 per cent of Canadians have drug insurance, but the survey did not distinguish between public and private plans.

Dr. Law said there are several reasons that patients fail to take medications as they are directed to do by health professionals: They don't like the side effects, they are forgetful, they feel they are no longer necessary, and so on.

But he said lack of affordability is one of the chief reasons and it is important to understand the extent of the problem because "it's amenable to policy action."

In this case, Dr. Law said, the obvious solution is to ensure that everyone can afford necessary prescription drugs. There are several ways of doing so, including instituting universal drug insurance (pharmacare), lowering drug prices, subsidizing drug costs, or targeting programs at those who are unable to pay now.

"You want to be careful and thoughtful about who you make policy for so you meet the needs out there," he said.

The study shows that those who have the most difficulty paying for their drugs are patients with chronic conditions that entail recurring drug costs. Low-income citizens also struggle, even if they are insured. (This because insurance often has co-payments or deductibles, or does not include dispensing fees.)

While Canada has universal public insurance for hospital and physician services, public prescription drug coverage tends to be limited to seniors and people on social assistance. (Quebec is the only province where all residents have drug insurance; low-income residents are covered by the state, but others must purchase it from private insurers.)

"Lack of universal drug coverage is a glaring hole in medicare," Dr. Law said.

Danielle Martin, a family doctor at Women's College Hospital in Toronto, said she routinely sees patients who cannot afford their drug treatments, and they tend to be the working poor.

"It's the taxi drivers, nannies and restaurant employees who often fall through the cracks," she said.

Dr. Martin, who is also president of the group Canadian Doctors for Medicare, is a staunch advocate for pharmacare, or adding prescription drugs to the services paid for by medicare. "Providing prescription drugs for free is not only the right thing to do, it also makes economic sense in many situations. A small cost outlay can sometimes prevent higher costs in the future," she said.

She cited a study in the New England Journal of Medicine showing that routinely providing medications to all heart-attack patients resulted in more people taking needed medications and having fewer complications.

Dr. Martin said the fear that universal public drug insurance is unaffordable is unfounded. "A national pharmacare program would save money and improve economic efficiency," she said.

Canadian spent $26.1-billion on prescription drugs in 2010, including $4.6-billion out-of-pocket, according to the Canadian Institute for Health Information.

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