Your health is important…

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TheGlobeandMail.com – Politics/Well Versed
September 30, 2019.   Samantha Mccabe And Jack Denton

Hey! It’s Samantha and Jack, the editors of Well-Versed. We’re happy that you’re joining us. We’ll be with you right up until the federal election. This week, we’re getting you well-versed on health care.

Health care is a constant in the lives of Canadians; from birth to death and all the scrapes in between. In Canada, we have a health-care system that is broadly comprehensive and affordable. As a political issue, health care is a hard-fought one because it is so personally important to so many Canadians.

Well-Versed is The Globe and Mail’s twice-weekly newsletter that aims to jump-start your conversations about the 2019 federal election. Write to us about which issues you want to hear about and express your opinion on the policies and people we’ve examined. If you’re reading this through a browser, you can subscribe to the newsletter.

A primer on Canadian health care and the role of the federal government

Canada’s system of publicly funded, single-payer health care is known as medicare. It was ushered in federally in the 1960s, after successful provincial transitions to a single-payer model, first in Saskatchewan and then in Alberta.

Medically necessary services offered by doctors are covered – that’s the overwhelming majority of physician and hospital services. Dental, vision and chiropractic care, as well as psychotherapy and cosmetic procedures not insured by the government are paid for out of pocket or through private insurance plans.

Health care, like education, is administered by provincial governments that dictate the specifics of coverage and may include additional benefits. So what role does the federal government play?

Canadian health care is legislated federally under the Canada Health Act, which dictates what provinces need to do to receive federal funding. If the federal government wanted to make vision care a publicly insured service, for instance, it would be done through the revision of this legislation.

The administration of health care is largely beyond the scope of the federal government. While federal party leaders on the campaign trail may pledge to address issues like long waiting times for service and widespread “hallway medicine,” which take up outsize space in provincial debates, this can only largely take the form of increased funding to the provinces.

There are, however, a number of important components of health care that the next federal government can address.

Pharmacare, the behemoth

Health reporter Kelly Grant put together this pharmacare explainer for Well-Versed readers:

When it comes to national pharmacare, nobody can accuse the federal Liberal Party of failing to do its homework.

In the 18 months before Liberal Leader Justin Trudeau presented his party’s health-care platform at a medical sciences building in Hamilton on Monday, the Liberals received two exhaustive studies totalling 312 pages of advice on pharmacare.

Both fact-finding exercises came to the same conclusion: Canada should establish a universal, publicly funded pharmacare program that does for prescription drugs what medicare did for medically necessary services offered in hospitals and doctors’ offices.

After all that, it was a touch deflating for some pharmacare enthusiasts when Mr. Trudeau unveiled a health platform that promised only a “down payment” on national pharmacare − and a relatively small down payment at that, considering the numbers thrown around in a national advisory council’s report.

So what, exactly, are the parties promising on pharmacare?

The Liberal plan

The health plan that Trudeau revealed on Monday promises an additional $6-billion over the next four years, representing a cost of $750-million in 2020-2021, rising to $1.75-billion in 2023-2024.

But that money is not solely for national pharmacare. It is for all of the Liberals’ enhanced health-care commitments, including making sure all Canadians have access to a family doctor or a primary health-care team; setting clear national standards for access to mental-health services; improving access to home care and palliative care; and implementing national pharmacare.

The Liberals know that nothing on that list can be accomplished by federal fiat. Trudeau acknowledged that a re-elected Liberal government would have to negotiate with the premiers to make its health agenda − including its pharmacare agenda − a reality.

The Advisory Council on the Implementation of National Pharmacare acknowledged that, too. Its final report urged the federal government to pick up the entire incremental tab of pharmacare as a way of enticing the provinces and territories to take part.

Although the report predicted that the bulk-buying power of a single government payer would contribute to Canada spending about $5-billion less per year on drugs than it would if the existing private/public system remained intact, the $5-billion is a savings to all types of payers, including workplace insurance plans and Canadians who pay out of pocket.

As the full cost shifted to federal and provincial governments, the council predicted a starter version of pharmacare covering essential medicines would cost an extra $3.5-billion a year and a full-blown program would cost an additional $15.3-billion.

“[The Liberal plan] falls short by a pretty wide margin − a billions-of-dollars margin,” said Michael Law, a University of British Columbia professor who holds a Canada Research Chair in access to medicines.

“Even with the starter plan under [national pharmacare Council Chair Eric Hoskins], all of the money [the Liberals] have put forward for all of health care isn’t enough to pay for that.”

The NDP plan

NDP Leader Jagmeet Singh reinforced his party’s long-standing commitment to pharmacare by rolling out its Medicine for All plan in the spring, five months before the campaign kicked off.

Singh is promising to adopt legislation, modelled on the Canada Health Act, that would see Ottawa provide a pharmacare transfer to the provinces and territories contingent on the jurisdictions offering universal coverage and adhering to a national formulary, a list of evidence-backed medicines covered for all.

If a drug is on the NDP’s formulary, at least one version would available at no cost; patients who want a brand-name drug when a generic is available would pay a $5 co-pay.

An arm’s-length body would set the formulary and negotiate discounted prices with drug companies, the NDP plan says. (The Liberals promised $35-million over four years in their latest budget to establish a similar body, which they are calling the Canada Drug Agency.)

The NDP has promised $10-billion a year for the federal portion of pharmacare. They’ve also promised to implement pharmacare by the end of next year, prompting Dr. Law of UBC to say, with a chuckle: “That would be very hard.”

The Green Party plan

Elizabeth May and the Green Party also vow to enact universal pharmacare by next year, but they are promising to spend even more than the NDP to make it happen.

Their plan, guided by the recommendations of the parliamentary standing committee on health, would see Ottawa pick up the full cost of pharmacare for the first two years, after which the provinces and territories would, together, be expected to pay just over half the annual cost.

The Parliamentary Budget Officer (PBO) pegged the cost of the Green plan at $26.76-billion in 2020-2021, rising to nearly $40-billion (including the provincial contributions) in 2028-2029.

The Greens and the NDP are both well back of the Liberals and Conservatives in the polls.

“But if the Liberals end up with a minority government supported by the NDP and the Greens and the Bloc, then we may have a much more interesting outcome when it comes to a pharmacare system,” said Katherine Fierlbeck, a political science professor at Dalhousie University.

The Conservative plan (or lack thereof)

The Conservatives haven’t made any specific campaign announcements about pharmacare, other than a news release criticizing part of Trudeau’s plan.

Conservative Leader Andrew Scheer has poured cold water on proposals for national pharmacare in the past. When the national advisory council released its report in June, he said: “I don’t believe that anyone thinks that when Liberals announce multibillion-dollar spending programs that they’re going to save money.”

You should also check out this video, which explains how national pharmacare could change what Canadians spend on prescriptions.

Reproductive rights and abortion access

Canada was one of the last developed countries to make the alternative to surgical abortion available. The medication that safely terminates pregnancies, made up of two oral pills that are together called Mifegymiso, was approved for use in 2017.

But during the course of a massive investigation, Globe health reporter Carly Weeks revealed that the approval of Mifegymiso has not been the game-changer it was initially thought to be. Instead, her analysis found that many primary-care providers avoid prescribing the abortion pill, and that the vast majority of prescriptions were given by just a few willing clinics predominantly located in urban centres. Many women are thus forced to travel up to hundreds of kilometres to those clinics, and then may face waiting lists and delays.

And in some provinces, government policy adds another hurdle to accessing Mifegymiso. Federal Health Minister Ginette Petitpas Taylor asked all provinces to remove abortion access barriers this past July, but was rebuffed by several provincial leaders who insisted their own standards were up to snuff.

In a political sense, the Canadian position on abortion seems pretty solid — officially, none of the parties will reopen the debate of legalisation, though Scheer had to clarify his position in August. He said he won’t bar his MPs from raising the issue but will oppose it himself, and accused the Liberals of trying to dredge up divisive social issues.

It was Elizabeth May’s turn to reaffirm her party’s position this month. After she told a CBC reporter that she wouldn’t control how her MPs vote on abortion, the Green Party had to clarify, saying that all of the party’s candidates say they support abortion and could risk being ousted from the party if they shifted on the issue.

The Liberal and Green parties both promise that their MPs will be told to vote to uphold abortion rights if the issue comes up. The NDP has pledged to whip all votes on the issue – a commitment to party discipline on the matter.

Mental health

It’s hard to reduce health to numbers, but we’ll let these statistics speak for themselves: As of 2018, more than 3-million Canadians reported unmet mental-health-care needs, according to Statistics Canada. If you’re looking to further understand the scope of mental-health issues in Canada, this report from the Canadian Mental Health Association is useful.

According to the Mental Health Commission of Canada, a national non-profit created by the federal government in 2007, up to two thirds of adults and three quarters of children and youth do not access services and supports to help them address their mental-health concerns.

While Canadians across the country struggle to access the mental-health services they need, one of the major areas open to interpretation is what kind of mental-health services should be covered. The Canada Health Act dictates that only medically necessary services provided by physicians or in hospitals are required to be publicly funded, but much of the work done to treat mental health is done in counselling and psychotherapy sessions provided outside of hospitals. These services must be paid for using private sources, such as employee benefit plans, and perpetuate inequitable access to care. No province or territory provides universal coverage for psychological, counselling and psychotherapy services.

As part of Trudeau’s Monday announcement, he promised that the Liberals, if re-elected, would improve nationwide access to mental-health services by strengthening the Canada Health Act to set coast-to-coast standards. The Liberals also want to “introduce new accountability standards so that Canadians can know what to expect from the public health system when they need it, and continue to crack down on private delivery and extra billing.”

The NDP pledges to make mental-health care available to all those who need it at no cost.

The Green Party promises to reduce waiting times for mental-health programs, put an emphasis on funding mental-health services in remote areas, prioritize the expansion of mental-health and rehabilitation services and look into mental illnesses caused by climate change and other social determinants.

(Editors’ note: How health care and mental health affect Indigenous communities is an issue that merits much more unpacking than we had room for in this edition. A future edition of Well-Versed will be devoted entirely to Indigenous issues.)

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