Before implementing national pharmacare, look at what provinces already offer

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Appeared in the Hamilton Spectator, October 23, 2018
Prescription Drugs

Modern medicines can improve both health outcomes and quality of life for those stricken with illness. As a result, policymakers and ordinary Canadians are understandably concerned about patient access, affordability and insurance coverage for prescription drugs.

However, recent calls for a national pharmacare program would have many believe that Canadians without private drug insurance—about one-third of the population—are out of luck. Fortunately, this is far from the truth. There actually exists a vast network of provincial plans to help Canadians, particularly those who may be at higher risk of foregoing prescriptions due to financial considerations, pay for their prescription medications.

Perhaps most crucially, recipients of social assistance have drug coverage at very low or no cost in every province. And provincial governments across Canada also cover the severely disabled and those diagnosed with conditions such as multiple sclerosis and cystic fibrosis.

But most provinces go even further and ensure that most seniors and lower-income individuals and families with high drug costs do not face undue financial pressure.

For example, British Columbia helps cover the cost of prescription drugs for residents through a number of different drug plans. The province’s largest plan, Fair PharmaCare, covers 70 per cent of the cost of eligible prescription drugs for families with a net income less than $15,000. Once a family spends approximately two per cent of its net income on drugs or related costs, the province pays for 100 per cent of any subsequent costs for the rest of the year. The plan also covers families with higher incomes but requires them to first pay out-of-pocket for their drug costs (up to two-three per cent of their income) before provincial coverage kicks-in. In addition, the province also maintains specific plans for individuals with HIV, certain psychiatric conditions and palliative care patients, among others.

Ontario operates three principal drug programs: the Ontario Drug Benefit Plan (for seniors), the Trillium Drug Program (an income-based plan for all Ontarians) and OHIP+ (for children and youth). The plan for seniors covers residents over 65 plus those living in long-term care or special care homes, Ontarians on social assistance and those with disabilities. Those eligible for the plan pay very low amounts upfront (ranging from $0-$100) before coverage begins, after which only small copayments (ranging from $2.00-$6.11) are required. Like B.C., Ontario also covers the cost of some medications for people with specific medical conditions such as cystic fibrosis, HIV infection, anemia, age-related macular degeneration and inherited metabolic disease.

Quebec takes a unique approach by mandating all residents not covered by private group insurance to enroll in the government’s drug insurance plan (RAMQ). Participating individuals pay premiums that range from $0 to $616 per year, depending on family income. Individuals must pay the first $19.90 of drug costs out-of-pocket, after which they only pay 34.9 per cent of the cost of eligible drugs up to a monthly maximum of $90.58 (after which all costs are covered). However, the premiums along with the deductibles and copays are waived for a host of different groups including Quebecers on social assistance, children under 18, full-time students and persons with a functional impairment. In fact, 1.4 million Quebecers pay no annual premium (39 per cent of beneficiaries) - 900,000 of which are not required any to make any direct contribution for their medication.

More generally, across the provinces, lower-income Canadians have access to some form of provincial insurance that helps limit out-of-pocket costs to a small percentage of income for prescription drugs, if not more extensive coverage.

That being said, there’s evidence that some Canadians may struggle to cover the costs of their prescription medications. For example, one study recently estimated that one of every 12 Canadians (8.2 per cent) who required a prescription in 2016 had difficulty paying for it. If true, policymakers should first identify these Canadians and help with the costs of their medication.

Somewhat bizarrely, however, the current prescription seems to be a national single-payer pharmacare program that would use scarce health-care dollars to subsidize everyone including the majority of Canadians who likely don’t need it.

Instead, we should help Canadians understand the coverage already available, and identify and support those Canadians falling through the cracks. Importantly, provincial governments should remain able to tailor drug plans to address the specific needs and preferences of their populations. A decentralized system also better fosters different experiences in each province, which makes it possible to better assess what works and what doesn’t. This dynamic may be lost with a national pharmacare program.

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