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In a study published on Tuesday in the journal Open Medicine, Joel Lexchin found that 22 of 528 new drugs Health Canada approved between 1990 and 2010 – 4.2 per cent – were pulled from the market.MARK BLINCH/Reuters


That's a word we will be hearing a lot more often in Canadian health care in the months and years to come.

That's because, while we tend to think of medicare as a highly-centralized, single-payer system, it is anything but.

The federal, provincial and territorial governments each have a publicly-funded health insurance program that covers all citizens in their 'territory' – for the provinces and territories it is geographic, for Ottawa, it is specific groups – First Nations, Inuit, Métis, as well as the Canadian Forces, veterans, the Royal Canadian Mounted Police and refugees.

Medicare covers hospital and physician services; it is far from all-encompassing. So are dozens of other programs that provide additional health-related goods and services to specific groups in their territory, such as seniors, people on social assistance, those living with disabilities, and others with extraordinary costs, such as cancer patients.

There was a striking reminder of this bureaucratic reality in the recent Alberta budget, with a passing mention that savings would be sought by consolidating and streamlining 18 health-related insurance programs.

That's 18 in addition to the Alberta Health Care Insurance Plan (AHCIP), the formal name for the medicare plan in the province.

"We realized there were some administrative efficiencies that could be achieved," Fred Horne, the provincial health minister, said in an interview.

So let's quickly review the 18-plus health insurance programs funded by the province (most are actually administered, under contract, by Blue Cross):

  • Seniors drug benefits: Everyone over the age of 65 gets coverage of prescription drugs. There are no premiums but the Blue Cross plan has a co-payment of 30 per cent, to a maximum of $25 per prescription. The province had planned to tie this benefit to income but reversed course after angry protests from seniors;
  • Seniors supplemental health benefits: Pays for health-related services not covered by AHCIP like ambulance transport and home nursing;
  • Outpatient cancer therapy drugs: Normally drugs are only covered if taken in hospital; this program pays for drugs for cancer patients who are treated as outpatients;
  • Outpatient specialized high drug costs: Offers prescription coverage for qualifying diseases; there are several programs under this rubric, such as palliative drug care coverage, multiple sclerosis drug coverage and diabetic supply coverage for those who need insulin to treat diabetes;
  • Alberta Monitoring for Health: Provides diabetic supply coverage to low-income people with diabetes who do not use insulin;
  • Pharmaceutical Innovation and Management: Provides funding to patients with high drug costs if they have rare conditions like Fabry disease;
  • Non-group supplemental health benefits: Albertans under the age of 65 who cannot otherwise get insurance can purchase it from Blue Cross for health services not covered by AHCIP;
  • Dental assistance grants for seniors: Provides Blue Cross dental insurance to low-income seniors;
  • Optical Assistance Grants: Provides Blue Cross optical care insurance to low-income seniors;
  • Alberta Aids to Daily Living Grants: Provides funding for health-related equipment like canes and hearing aids to people with long-term disability, chronic or terminal illnesses, but excludes structures like ramps and lifts;
  • AIHS Health-Related Assistance Grants: Provides a living allowance to people with a permanent disability that supplements social assistance and child benefits;
  • Child health benefit: Provides health benefits like prescription drugs, optical care and dental care to children of low-income families;
  • Adult health benefit: Provides health benefits to people who have left income support but still have a low income (the working poor);
  • Learner health benefit: Provides health benefits to adult students in an approved training program;
  • People Expected to Work or Working Health Benefit: Provides health benefits to people on social assistance who are actively looking for work;
  • People with Barriers to Full Employment Health Benefit: Provides health benefits to people with disabilities that limit their ability to work;
  • Child Intervention Health Benefit: Provides health benefits to children under guardianship or other court-ordered care.

Just reading the list is exhausting. But what stands out is that most of these programs have the same goal – to make prescription drugs available to those who could not otherwise afford them.

Yet the programs tend to operate independently, with their own formularies (lists of approved drugs) and purchasing agreements. That makes no sense.

"The big change is we're going to have a common formulary that covers a broad range of coverage but still allows us some flexibility," Mr. Horne said.

The next challenge is to bolster catastrophic drug coverage, to create an insurance plan that ensures no one is bankrupted or denied care because they can't afford necessary prescription drugs. Like Alberta, every province and territory has some piecemeal plan(s).

But, as Mr. Horne noted, the advent of many new costly drugs for rare diseases requires a response on a national scale.

"We have to pool our risk and use our collective buying power. We shouldn't be doing this alone," he said.

The Alberta Health Minister will be pushing for a national catastrophic drug program, and there should be a lot of interest from other jurisdictions.

But a catastrophic drug plan is not pharmacare.

Despite the myriad programs and the fact that many full time workers get supplemental health benefits (prescription drugs, dental, optical care, etc.) through their employers, one in five Albertans still does not have coverage beyond the basics. In some other provinces, the percentage of citizens without prescription drug coverage is even higher, and the situation is growing worse as employers dump benefits.

That reality should remind us that our universal health system is far from universal.

Bringing some order and efficiency to existing programs through consolidation will help. Catastrophic drug coverage will help even more. But there will still be many Canadians unable to afford their prescription drugs.

What we really need – for reasons of economic efficiency as well as social justice – is to extend medicare coverage beyond hospital and physician services to areas such as prescription drugs.

To date, only two provinces have embraced universal prescription drug coverage, Quebec and New Brunswick. Others are moving in that direction, but too slowly.

The consolidation we really need is a consolidated effort to create a national pharmacare plan.

Let's be clear that there are many way to achieve this; it doesn't have to be a single, state-run entity.

But the starting point is embracing the philosophy that drug coverage should be an integral part of medicare, and then work to make it so.

André Picard is The Globe's public health columnist.