Pharmacare for All?

On September 30, Dr. Danielle Martin delivered an eloquent speech on improving health outcomes for Canadians, with particular emphasis on Nova Scotia.

She makes her case for three specific initiatives, one of which is a National Pharmacare program. She begins with the story of “Ahmed” (not his real name), a taxi driver in Toronto. He can’t afford to both support his family and buy the drugs he needs to treat his diabetes and cardiovascular problems, costing hundreds of dollars per month. That can easily lead to much more expensive hospital treatment when the conditions get out of control.

To Dr. Martin

“The most obvious way to fix this problem would be to bring prescription drugs under Medicare… But if we can’t summon the political will right now to cover all prescription medications, let’s focus first on those with the biggest bang for the buck.

Let’s choose 20 drugs—or 50, or 100—that are commonly used to control chronic diseases like asthma, diabetes and high blood pressure. If we can agree nationally to go in together on public coverage for these medications, we can cover them for everyone, including Ahmed.”

Dr. Martin makes skillful use of anecdotes, but the problem is that they rarely tell us much about the population as a whole. Ahmed is no exception.

In Nova Scotia there are programs providing a long list of drugs for seniors, beneficiaries of the Income Assistance program, children in low income families, children in care programs, and persons with disabilities.

As well there are income based programs for cancer patients, diabetes patients, and under-65 long term care residents.

Finally there is a Family Assistance Program to which anybody can apply. Like the other programs it covers thousands of drugs, and serves to keep costs from taking too much of a family’s income. For example a person earning $35,000 with three dependants pays for the first $780 in drug costs, and 20% thereafter. If those copayments reach $1,560 the province’s share increases to 100% for the rest of the year. More than 40,000 Nova Scotians benefit from Family Pharmacare.

Taken together these programs provide an impressive array of protections against unaffordable prescription drug costs. The Pharmacare budget in Nova Scotia this year is $265 million.

Ontario has similar programs, including a more generous version of the Family Pharmacare Program. If Ahmed makes $35,000 per year his drug costs after the first $986 can be reduced to $2 per prescription, in total much less than $100 per month.

Apparently Ahmed has chosen not to apply for the Ontario program, finding the paperwork difficult and even the residual cost hard to manage. Dr. Martin’s failure to mention this (in a speech that runs over 4,300 words) is a glaring omission.

As she points out 70% of Nova Scotians are already covered by private or public drug plans. If a national drug plan becomes available the biggest winners will be large corporations such as financial institutions, manufacturers, and other big employers. They will no longer need to provide coverage to their employees if government is doing so.

Also experiencing big savings would be the pharmaceutical companies who currently provide substantial cost relief to those who need expensive drugs and can’t afford even the amounts up to the limit where Family Pharmacare takes over.

So much of the spending on a universal program will go to benefit big corporations, hardly the group which new initiatives should aid. That hardly makes sense for a province that has been unable to pay for existing programs without running a deficit.

Dr. Martin acknowledges as much, saying she would like to see the federal government pick up the tab. Needless to say Health Minister Glavine and his counterparts across the country would be delighted if it did so, since it would free the province of responsibility for providing needs-based programs.

That does not improve the argument for spending tens of billions on a universal program. It is unlikely that the current federal government will choose any national program for pharmaceuticals, or that any future government would be wise to do so.

This is not to say that the existing system is perfect. Cancer patients that used to be treated in hospital, for free, are now often sent home and prescribed shockingly expensive medications as therapy. The potential for support from private insurers, Family Pharmacare, and in some cases the drug companies is eventually sorted out but in the meantime the patients and their families experience considerable stress about costs at an already difficult time.

Perhaps the province should front end the first month or two of supply, recouping the cost from insurers and drug companies when their contributions become available.

Secondly, the existing program could be made more supportive, especially for those who are off work because of an illness requiring expensive medication. A worker who was making $67,000 will have to pay between $11,000 and $15,000 (depending on the number of dependants) toward drug costs before the province covers 100%. That threshold will of course be substantially reduced as income reduces.

Thirdly, active administrative support, already available to cancer patients, should be provided to others with chronic conditions to help them navigate the system so that they receive the benefits to which they are entitled.

Well focused initiatives on all three of the above would not add a lot of cost and would, as Dr. Martin argues, probably save money in the hospital part of the system.

Dr. Martin’s well-crafted speech raises important questions about the adequacy of support to patients who are not hospitalized, but need expensive ongoing drug therapy. Her proposed solution is expensive and inefficient. Her argument in favour of it is not persuasive.

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