Chance for a Change

The window for Pharmacare is closing, will the CASA get it done?

I’d written about the CMA Health Summit a few weeks back with posts on health and global heating and the dangers of false balance in the private-public health care debates .

Returning once more to that summit, the penultimate presentation was a panel that included newly minted Health Minister Mark Holland in conversation with even more newly minted CMA President, BC family doc Kathleen Ross. They had a wide-ranging conversation on the challenges facing health care and what needed to be done in the next 60 days. The line that stuck out most clearly for me was when Minister Holland said about Pharmacare that “We are committed to introducing legislation in the fall, very soon.” This is an encouraging statement, though just how encouraging depends on what he means by Pharmacare.

Adding universal coverage of essential medicines has been the biggest push of those who would defend and expand Medicare for decades. Canada is the only high-income country in the world that has universal public health care without universal public drug coverage (the United States is the only high-income country with neither.) As a result, a quarter of Canadians leave prescriptions unfilled or skip or split doses because they can’t afford to take their medications as prescribed. One in five Canadians has no drug coverage at all, and lower income families are less likely to have any drug coverage at all.

I see this less in my own practice, as I work in on-reserve and inner-city communities or at the REACH refugee health clinic. Most of my patients are covered by existing formulary programs through First Nations Inuit Health Branch or the Interim Federal Health Program. There are limitations to what’s available, but I can’t imagine how we would provide care for these low-income communities without the coverage that exists.

Not all of our patients at WestSide have that coverage, however, and I certainly do see patients having to make difficult choices. I often think of Barry, who works full-time for the city, but doesn’t make enough to pay for his diabetes medications. He ends up splitting pills or skipping days and has struggled to get his sugars under control, leaving him at higher risk for heart attacks and kidney disease.

Stories like Barry’s are common across Canada. Canadians are rightly proud of Medicare and the idea of a universal, publicly-funded health care system. However, that idea of universal coverage is incomplete. While Medicare covers over 90% of physician hospital services are covered, it’s only 39% for medications. This is much less than other high-income countries with comparable universal public health care. Multiple national studies, from the 1964 Hall Commission to the 2002 Romanow Report to the 2019 Advisory Council on the Implementation of National Pharmacare led by former Ontario Minister of Health Eric Hoskins have recommended expanding Medicare to include drug coverage. Canadians want to see Pharmacare, with a 2020 Angus Reid poll showing 86% of Canadians surveyed in favour of the idea, and 77% saying it should be a high priority for the federal government.  

Failing to include medications in our national health insurance program not only leaves patients footing the bill, it also makes those medications more expensive. Canadians pay among the highest prices in the world for prescriptions. Australia’s bulk-buying means they pay nearly 30% less for all medications than Canada. Lipitor, a commonly used cholesterol-lowering drug, costs Canadians ten times as much per pill as it does in New Zealand. The Hoskins report estimated that a national Pharmacare program that included an evidence-based formulary and bulk buying would save Canadians $5 billion a year.

And those are just the savings in drug costs. While more challenging to calculate, the real savings – both in health care dollars and in quality of life – may amount to billions more. The Hoskins Advisory Council report concluded that Pharmacare could prevent 220,000 emergency department visits and 90,000 hospitalizations. It is so much easier and less expensive to treat someone’s hypertension, COPD, HIV or diabetes than it is to care for their stroke, respiratory failure, meningitis or amputated limb. Universal coverage helps us to work upstream from acute care, managing illnesses early to save money and lives.

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Despite the evidence and widespread public support, no federal government has been willing to take this important next step in Medicare. Until now, that is. The passing of Pharmacare legislation by the end of 2023 is one of the conditions of the confidence and supply agreement (CASA) between the NDP and the Liberals that is keeping the minority Trudeau Liberals in government.

Which leaves us with two questions:

1. are the Liberals willing to make the leap to real Pharmacare or if they will try to pass off a half-measure as enough to satisfy the CASA?

2. if they don’t bring in full Pharmacare, will Jagmeet Singh and the NDP pull the plug?

NDP Health Critic Don Davies has said that the latest version of Pharmacare legislation that he’s seen is “Not where we want it to be,” with where he wants it to be meaning a fully universal, single-payer program. Advocacy groups like Canadian Doctors for Medicare and Pharmacare 2020 are warning against “fake Pharmacare” that falls short of universal. Former Finance Minister Bill Morneau responded to the initial Hoskins report saying that he preferred a “fill-the-gaps” approach instead of a universal system. Not only would this be highly inefficient and leave many patients falling through those gaps, it would interfere with the ability to negotiate lower prices and buy in bulk. The Hoskins report was clear on this, saying “Medicare doesn’t just fill the gaps and neither should Pharmacare.”

It's no secret that Justin Trudeau’s government is in trouble, falling in the polls and in the confidence of Canadians. They also run the risk of facing voters sooner if they don’t follow through on their CASA commitments. Recent decisions to repeatedly back away from promises to reduce drug prices suggest an outsized influence of the pharmaceutical lobby by this government. If they continue to outsource their drug policy to the companies that profit from the status quo, we will see empty language or half measures.

If that is their approach to Pharmacare legislation, the federal NDP has to call their bluff and say adios to the CASA. Anything less would be an abandonment of principles with dire political consequences. Singh’s comments before the 2019 federal election were clear as day: "Now, will the Liberals continue to stand with big pharma and the insurance lobby, or will they stand with Canadians and the NDP to finally implement a promise they abandoned over 20 years ago?" He will have to back up those strong words with action if the Liberals fail to follow through.

Or the Liberals could follow the advice of the Advisory Council they commissioned and introduce a stepwise version of Pharmacare that starts with the most essential medications first. This would be, in the words of Eric Hoskins, “the biggest, most positive transformation in our healthcare system, since medicare and the Canada Health Act.” It’s an opportunity for a legacy and a chance at a new relationship with Canadians in advance of the next election. It’s a chance to reverse the erosion of Medicare by building up instead of tearing down with privatization. More importantly, it’s a chance lower drug prices and get patients the care they need.

Whether this government will make the wise choice or the worse choice depends on their perception of where the public is on this issue. Hearing from you would help, and you can find an easily adapted draft letter here. Sharing today’s post wouldn’t hurt either.

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