“I beg your pardon, I never promised you a rose garden.”
That refrain, from the classic country song by Lynn Anderson, is one that springs readily to mind during the current discussions of pharmacare.
In last week’s budget, Finance Minister Bill Morneau announced the creation of the Advisory Council on the Implementation of National Pharmacare (ACINP) with a “mandate to study, evaluate and ultimately recommend options on a path forward on pharmacare.”
Yet, for some, this was taken to mean that, in short order, Canada would have a national single-payer system that would pay for everyone’s prescription drugs.
Mr. Morneau had barely finished planting a seed and advocates were dreamily breathing in the scent of bouquets.
Let’s not get ahead of ourselves.
The philosophy underlying medicare is that no one should be denied essential care because of an inability to pay. Prescription drugs can be essential to care, so ensuring universal drug coverage is a laudable and necessary public policy goal.
But there is more than one way to get there, and there is a cost.
The role of Dr. Eric Hoskins, who will head ACINP, should be to study the options, cost them out, explain the trade-offs, and determine which is the most politically palatable.
Drug coverage in Canada is a patchwork of private and public insurance programs. About 26 million Canadians have private drug benefits, largely through employers. There are 102 public drug insurance programs, but that still leaves 700,000 people with no drug coverage, and an estimated 3.6 million with inadequate coverage, according to the Parliamentary Budget Officer. An analysis by the Conference Board of Canada found far fewer people lacked coverage.
Regardless, there are three possible solutions to ensuring access for all: 1) patch up more of those cracks with those whose coverage is lacking, such as low-income workers, the self-employed and many seniors; 2) make drug insurance mandatory for all citizens, and offer subsidies to those who cannot afford private insurance or are not covered by existing plans (an approach taken by Quebec) and; 3) create a national plan that covers everyone, the way medicare does for hospital care and physician services.
The third option has the loudest and most enthusiastic proponents. We are told that a national plan could save anywhere from $4-billion to $11-billion on the $28.5-billion prescription drug bill (in 2015).
Those purported savings would come from joint buying, more strictly regulating drug prices, more aggressive use of generics, and limiting the formulary (the list of drugs that are covered.)
Pharmacare does not mean all drugs will be covered for all people all the time. Ontario’s new public formulary covers 4,400 drugs; some private drug plan formularies cover 12,000 drugs.
While a single, national plan would theoretically save money on drug purchases, it would also mean a large-scale shifting of costs from the private sector to the public sector – a net $7.3-billion annually, again according to the PBO.
The single biggest impediment to pharmacare is the unwillingness of federal, provincial and territorial governments to absorb those costs and then increase taxes to pay the bill – even if the consumer comes out paying less in the long run.
In Canada, we have had public hospital insurance since 1957, and public insurance for physicians since 1966. There has not been a large-scale national health initiative since then.
The deafening silence from the provinces – who ultimately pay for drugs – on this issue does not indicate enthusiasm.
A national plan means new infrastructure and bureaucracy. Yet, no agency exists today that provides a health service coast-to-coast jointly funded by federal, provincial and territorial governments, with one small exception. That anomaly is Canadian Blood Services, which collects blood and distributes blood and blood products across Canada (except for Quebec), and it only came to be after the worst public health disaster in the country’s history, the infection of tens of thousands of people with the AIDS virus and the hepatitis C virus through contaminated blood.
Could that model be expanded and made to work for the purchase and distribution of all drugs?
Pharmacare – meaning insuring that every Canadian has access to necessary prescription drugs regardless of ability to pay – is a philosophy with few detractors.
But the technical and political impediments are many and real, and we have to stop pretending otherwise.
If Dr. Hoskins is going to move this idea along, even incrementally, he cannot afford to wear rose-coloured glasses.