Has there been any progress with Pharmacare?
In 1964, the Royal Commission on Health Services, or “Hall Commission,” named after Supreme Court Justice Emmett Hall, produced recommendations for a universal, public Pharmacare program for Canada, following Canada’s introduction of Medicare. Justice Hall argued that access to necessary medicines should be introduced as an additional benefit of the public health services program in Canada. The Hall Commission called for the federal and provincial governments to collaborate, compiling a list, or formulary, of medicines based on their clinical and economic value that would be made available to Canadians as part of a publicly-administered program.
In 1997, the National Forum on Health, an expert panel chaired by Prime Minister Jean Chrétien, recommended a universal, publicly-administered drug benefit program to promote access to necessary medications and to control costs of prescription medications. The National Forum similarly recommended that provinces include in their universal, publicly-administered drug plans necessary medications that have been shown to be both clinically and cost effective. The National Forum added the recommendation that such a program would only impose user fees on products that are not the most cost effective treatment options. For example, users pay a fee when more expensive brand name drugs are used rather than the less expensive, but equally effective generic drugs.
In 2002, the Commission on the Future of Health Care in Canada, or the Romanow Report, named after past premier of Saskatchewan Roy Romanow, followed suit and recommended that Canada’s federal and provincial governments collaborate to integrate medically necessary prescription medications within the already-existing Medicare program. The Romanow Report added that including “catastrophic” drug coverage would promote the objective of bringing prescription drugs under the Canada Health Act.
In November 2012, the Canadian Association for Health Services and Policy Research (CAHSPR)
held a conference, “Ten Years Since the Romanow Report: Retrospect…and Prospect,” which highlighted stagnation in progress in the area of access to necessary medicines for Canadians, despite our universal Medicare system. This conference noted the complexities of Canadians’ health needs, Canada’s multijurisdictional system, and the gap in addressing the social and economic determinants of health. Roy Romanow, speaking at this conference, heeded that:
“Equity trumps income. Access to health care should be based on need and the same level and quality of care should be available to all. Values matter…Respect matters. Public support for health care is not given freely. It is given in exchange for the commitment that the system will be there…when they need it. [And] evidence matters. We cannot build and sustain a durable, effective, and responsive health care system on guesses and unproven assumptions.”
In early 2013, health policy and services experts from across the country gathered in Vancouver for the “Pharmacare 2020: Envisioning Canada’s Future” conference on equal and affordable access to necessary prescription medications for all Canadians. The conference fostered collaboration and discussion between medical practitioners, researchers, policy makers, patient advocacy groups, not-for-profit research organizations, and industry representatives on pricing, patenting, availability, coverage challenges, potential roles of private insurance, and visions for Pharmacare.
Currently in Canada, there is a patchwork of public and private drug plans. Through this melange of plans, twenty-four percent of Canadians have no drug coverage and eight percent do not use prescription drugs as prescribed because of the high cost. Both families and individuals who are precariously employed or working low wage jobs have limited access to prescription medications. When people do not take their medications as prescribed, the healthcare system incurs greater costs. Because of inconsistent use, people end up in emergency rooms and doctors’ offices when their conditions worsen.
Lack of access to prescription medications disproportionately affects the low-income population. In 2014, people in the lowest income quintile, or the poorest one-fifth of Canadian households, spent twice as much out-of-pocket on prescription drugs per year: $645 vs. $300, respectively. Furthermore, research indicates that prescription costs can play a role in bankruptcies. A study on Canadians who filed for bankruptcy between 2008 and 2010 found that seventy-four and a half percent of respondents who had a medical bill within the last two year reported that prescription costs were their biggest medical expenses.
Poor social determinants of health, particularly poverty and income, are associated with poor health outcomes and increased disease incidence. Risk can be magnified if individuals are unable to access prescription medications. It follows that those who are most at risk for illnesses are especially prone because they cannot access important medications. Canada’s lack of a national Pharmacare program is contributing to health inequities and putting many low-income Canadians at significantly more risk.
Until a national Pharmacare plan is implemented, health practitioners should ensure that they are assessing patients’ abilities to pay for medications on a regular basis. Primary care providers can include questions about income and other important social determinants of health when making their assessments, gauging their patients’ abilities to pay for medications that they have prescribed. If patients are not adhering to their medication regimes, it is important for healthcare providers to find out whether cost is a factor. To reduce costs, patients can consult with their doctors to determine if every prescription is necessary, if fewer medications would result in similar outcomes, and if generic alternatives are available.
Healthcare providers also have a role in advocating for a Pharmacare strategy and can encourage their professional associations to join in advocating for reduced prescription costs through a plan.
The World Health Organization has affirmed that all nations have the obligation to ensure equitable access to necessary medicines as part of their universal health care systems. Canada is the only developed country with a universal health care system that does not provide universal prescription drug coverage. Today, Canadians, including individuals, interest groups, and politicians, continue to advance arguments in favour of Pharmacare as an expansion of public health care coverage in Canada. The theory, evidence, and policy experience have led to a series of recommendations by Pharmacare 2020, a Canadian health policy research collaboration. These recommendations have been endorsed by 281 research leaders in health policy, health economics, health services research, medicine, pharmacy, nursing, and psychology. These recommendations can be found at pharmacare2020.ca. These recommendations are founded on four principles and key policy goals: universal access to necessary medicines, fairness in the distribution of prescription drug costs, prescribing safety and appropriateness, and value for money, affording Canadians with maximum health benefits per dollar spent.
These foundational principles inform four public policy recommendations. First, universal coverage of selected necessary medicines for a national formulary should be of little or no direct cost to patients through Pharmacare. Second, financing medically necessary prescription drugs should be conducted at the population level, without needs-based charges including deductibles, coinsurance, risk-rated premiums, or external plan sponsors. Third, for an effective national program, a publicly accountable body must be established to manage and integrate the best available data and evidence into drug coverage, prescribing, and patient follow-up decisions. Fourth, Pharmacare should be a single-payer system, with a publicly accountable management agency that operates under a transparent budget to secure the best health and cost outcomes for Canadians, working in conjunction with Medicare to ensure its universality, comprehensiveness, and sustainability.
This article was written by Adrienne Shnier and Sarah Katz. Adrienne is the Editor-in-Chief of the Osgoode Health Law Association. She received her PhD in Health Policy & Equity, with a specialization in conflicts of interest, medical education, and pharmaceutical industry promotion from the School of Health Policy and Management at York University. Sarah is Co-President of the Osgoode Health Law Association, is a Registered Nurse and a former Public Health Nurse, and holds a Master of Health Science in Bioethics from the University of Toronto.
This article is part of the Osgoode Health Law Association’s Perspectives in Health column. Keep up to date with the HLA on Facebook (Osgoode Health Law Association, Osgoode Health Law Association Forum) and Twitter (@OsgoodeHLA).
If you would like to write with the Osgoode HLA, please contact Adrienne Shnier (AdrienneShnier2016@osgoode.yorku.ca).