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Canada is “a country of perpetual pilot projects,” former health minister Monique Bégin once famously said.

Despite all the hype surrounding the “historic” Bill C-64, or the Pharmacare Act, what’s being floated is really nothing more than a giant pilot project.

The proposed legislation declares the federal government’s “intent to work with provinces and territories to provide universal, single-payer coverage for a number of contraception and diabetes medications.”

Is this the beginning of a broader, state-run program of first-dollar coverage for all drugs? Perhaps. But it’s certainly not a given.

Pilot projects don’t have a very good record of being scaled up in Canada, and this one starts with a lot of question marks. There is no timeline, no guaranteed funding, no clear end goal, and lukewarm enthusiasm from some provincial partners.

On Sunday’s edition of the CBC’s Cross-Country Check-Up, host Ian Hanomansing asked two questions: “Are you able to afford your medications?” and “Can Canada afford a national pharmacare plan?

The answer to the first question is clearly “No” for far too many Canadians, and in a country where medicare’s underlying philosophy is that no one should be denied essential medicare owing to an inability to pay, that needs to be fixed.

But the second question is the wrong one. Clearly, a country that wants citizens to have decent, equitable health coverage can’t afford to leave prescription drugs out of the mix. The question we really need to ask is: How can we provide essential medications to all Canadians efficiently, and equitably?

There is no doubt we have the money. Last year, Canadians spent $47.8-billion on prescription and non-prescription drugs – that’s 13.9 per cent of the country’s total health spending, which is $344-billion annually.

The non-system we have is a patchwork of private and public plans that leave most Canadians with drug coverage. However, about one in five people have inadequate or no coverage.

There were, at last count, 102 public drug-insurance programs covering seniors, social welfare recipients, some people with disabilities, and patients with specific medical conditions. But public coverage varies wildly between provinces. Like much health coverage in Canada, it’s a postal code lottery.

Most Canadians, about 27 million, have drug insurance through private plans or their employers. There are an estimated 113,000 private plans and coverage varies, with premiums, co-pays and so on. But private insurers generally offer more extensive coverage than public plans.

The big unknown, with both the new pilot project and a broader state-run pharmacare program, is: How much of the bill would the federal government absorb?

Public funding of contraceptives and diabetes meds alone would cost an estimated $1.5-billion a year. Much of the cost of these drugs is now paid by provincial plans and private insurers; it’s not clear how much the feds will contribute. Negotiations will be arduous and slow. To give you an idea, one year ago the feds pledged $1.4-billion to pay for drugs for rare disorders. There is still no deal with the provinces.

The Parliamentary Budget Office estimates that a single, state-run pharmacare plan would cost about $40-billion, roughly $13-billion more than public plans are now paying.

There are many crying needs in Canada’s crumbling health care system. Is taking over costs that are currently paid for by private insurers really the best way the government can spend limited resources?

A sounder, more pragmatic approach would certainly be to funnel public dollars toward those who have inadequate coverage (such as low-wage workers) and bolstering existing public drug programs so that, for example, every person with diabetes can afford their meds, and low-income seniors are not saddled with co-pays.

This is the approach the federal government has taken with the Canadian Dental Care Plan. The CDCP does not replace private insurance plans, but rather covers those who can’t afford dental care, based on family income (a means test) and it includes co-pays. The Liberals have been unclear on where they stand philosophically on how health coverage is provided.

When pharmacare is discussed, a popular rhetorical phrase is that Canada is the only universal medicare system that does not include prescription drug coverage.

There is truth to that statement. Among peer countries, Canada has the least-universal universal health insurance program.

But universality means everyone has access to essential care, including medications. It does not mean programs must be uniquely state-run and state-funded – and they are not in most countries.

Instead of politically expedient pilot projects, we need a more targeted approach to helping those in need – dare one suggest, a vision even?

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