National pharmacare is part of the election platforms of three federal political parties. The three plans differ but opinion polls show most Canadians do support a national insurance scheme for prescription drugs. Will election promises bring the benefits Canadians need?
The situation now is that all provincial public plans provide at least some coverage for seniors, low-income residents and persons with disabilities, and most also have means-tested programs to protect against catastrophic costs. However, coverage is subject to out-of-pocket copayments and deductibles that vary by province but must be paid before financial assistance can be claimed.
Large differences also exist between provinces in how many medicines are covered. Quebec’s public plan, the most comprehensive, covers around 8,000 products, Ontario’s about 5,000, and other provinces fewer. The biggest differences across provinces are in the coverage of new drugs. Where they are covered, medicines are often limited to patients likely to benefit from them, which is only reasonable. But these criteria sometimes make little or no clinical sense to the specialist physicians who treat the patients and they are frequently so restrictive only one or two patients qualify.
Canada already has the basis of a national system for cancer drugs, which, when administered in hospital, are covered in all provinces with federal assistance under the Canada Health Act’s cost-sharing provisions. Although patients welcome the current trend towards taking cancer drugs taken at home, which reduces the time, cost and disruption of going to the hospital, take-home cancer drugs receive no federal cost-sharing. The four western provinces cover their cost but the other six do not.
At the moment, there is substantial inequality in drug coverage, both across and within provinces, and a strong need for better coverage to improve health outcomes for Canadians who do not have private insurance. But reform needs to be done in the best interest of patients.
The election platforms of the Liberals, Greens and NDP focus on enabling low-income Canadians to afford medicines that are mostly used in primary care, an approach that fits with the politics of spreading resources widely so as to benefit as many people — and, to be cynical, as many voters — as possible.
Rolls Royce, Buick or Lada?
But just as shopping for a new car can be a choice between expensive, like a Rolls Royce, mid-range, like a Buick, or cheap, like a Lada, the pharmacare election promises offer big differences in price and quality.
Given the choice, what Canadian wouldn’t want the Rolls Royce drug plans available to federal politicians, civil servants and many of the academic advocates of pharmacare, who are covered through their private group insurance for all 13,000 drugs approved by Health Canada? If the Rolls weren’t available, however, would they be satisfied with a Buick drug plan that included coverage of specialized drugs not currently insured? Almost certainly.
Unfortunately, even a mid-range program based on the most comprehensive existing public drug plan (Quebec’s) will cost a lot of money. The Parliamentary Budget Officer estimated the cost, using generous but unrealistically optimistic assumptions, to be $19.3 billion. With more appropriate assumptions, the Canadian Health Policy Institute produced an estimate of $26.2 billion. For its part, the current federal government’s Advisory Council on the Implementation of National Pharmacare put the cost at $40 billion, while the tax consulting company RSM Canada recently projected the cost to be $48.3 to $52.5 billion.
What about the parties’ pharmacare cost projections? The Green Party offers $26.7 billion, which as the estimates just quoted suggest, is barely sufficient for even a mid-range plan. The Liberal and NDP promises of $6 billion and $10 billion, respectively, are totally inadequate: they would lead to a plan like a Lada — a mode of vehicular transport famous for claiming to be a car but never actually driving like one. It’s hard not to conclude that Canadians are being offered lowball cost estimates just to win votes.
Or could it be that the parties plan to force down drug prices to fit the inadequate pharmacare funds they intend to make available? The present federal government has recently moved in this direction for new drugs by changing the regulations governing the agency that sets ceiling prices for such drugs. But cheap will cost. Imposing huge price reductions will deter manufacturers from launching new innovative medicines here, which denies Canadians access to their benefits.
Facilitating access to necessary medicines for low-income Canadians is a worthy objective but achieving it does not require national pharmacare. Exempting such patients from copayments and deductibles, as British Columbia has done, would attain this goal much more simply and effectively.
National pharmacare should have inclusive objectives that not only allow low-income residents to access basic medicines but also ensure that patients who need specialized drugs, especially the higher-cost innovative genetic therapies that may be the only effective treatment for their disorder, are not left behind. Unless whoever forms the federal government after the election provides: adequate resources for good-quality national pharmacare, a guarantee of long-term funding, and a roadmap for integrating it with existing provincial programs, Canadians hoping for improved access to medicines are unlikely to be satisfied.
The bottom line? Be wary of political parties selling a low-cost Rolls Royce. It’s going to end up either costing a lot more than advertised or performing much more like a Lada.
Nigel Rawson is president of Eastlake Research Group and an affiliate scholar with the Canadian Health Policy Institute. John Adams is cofounder, president and CEO of Canadian PKU and Allied Disorders Inc. and volunteer board chair of the Best Medicines Coalition.
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