COVID-19 is a terrible virus but offers a valuable lesson. Longstanding health disparities based on race have become front page news, driving home the importance of protecting everyone’s health.
Yet, a new Angus Reid Institute poll shows that many Canadians don’t have insurance that covers essential medicines and many commonly skip taking their pills because of the cost. The national survey confirms that in the midst of a global pandemic, one in four Canadian households has inadequate prescription drug coverage. Women and racialized people (“Canadians who identify as a visible minority”) are more likely to report having no insurance or partial coverage. Lower income households are more than twice as likely to be uninsured or under-insured as those with household incomes over $100,000. Women are more likely to report being uninsured or under-insured than men.
COVID-19 has made this situation dire: more than half a million Canadian houses have lost prescription drug coverage during this year of unprecedented public health and economic crises.
The interaction between race, drug coverage and COVID runs deep. For instance, having poorly controlled diabetes increases the risk of dying from the virus. One would think that every Canadian with diabetes should be all set to face down the pandemic: insulin was discovered almost a hundred years ago in Toronto; the rights to it were sold for just $1; and we have a publicly funded healthcare system. Despite that, millions continue to go without the drugs they need, like insulin.
Accessing medicines can be the difference between life and death. Sadly, the death toll from COVID-19 in Canada has now passed 10,000. Chronic diseases like diabetes will kill more than 20,000 people this year. The number of lives saved through better access to medicine is hard to know exactly but it is likely in the thousands.
So, if we are “all in this together,” why are some riding crowded buses during a pandemic to jobs that don’t provide insurance for insulin and other life-saving medicines?
Canada is the only high-income country with a universal healthcare system that does not include coverage of prescription drugs. Our provincial plans provide some coverage for people receiving social assistance or some seniors. But too often, prescription drug coverage is a “perk” associated with a good-paying job in an organization large enough to offer extended health benefits to its employees. Racialized Canadians and women are less likely to work in such jobs than white Canadians and men, making pharmacare not just a health issue but also an issue of racial justice and gender equality.
Progress in addressing systemic racism has been slow in Canada. Implementing pharmacare would mitigate one of the ongoing harms of systemic racism: poor access to life-saving medicines among racialized people. And like other approaches to addressing systemic racism, implementing pharmacare would ultimately be good for everyone.
Every credible estimate of the cost of a national pharmacare program – including estimates by Canada’s Parliamentary Budget Officer and the Department of Finance – has found that such a system will save Canadians billions more than it will cost governments to run.
Canadians understand this. The Angus Reid Institute study reported that people of all political stripes support the inclusion of medicines in our publicly funded system. Nearly nine in 10 Canadians support the idea of pharmacare, eight in 10 want their provincial governments to work with the federal government on it and more than seven in 10 say it should be a high priority for government – even during the pandemic.
One of the things COVID-19 has taught us, and continues to teach us, is that when we take collective action to support our health and that of our neighbours, it works. There are many impressive examples of reduced transmission and “flattening of the curve” – the fact that schools are open across most of the country is a victory, and the list goes on. Pharmacare could be another pandemic success story – the need has never been greater and the support for it never more clear.
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Before COVID, many patients who don’t have drug coverage (or suboptimal drug coverage) will go without therapies. The most affected populations are diabetes and asthma/COPD. New treatments such as SGLT2i or GLP1 agonists – although endorsed by diabetes guidelines due to their evidence of CV benefits, cost at least $100/month if not more. Recommended inhalers such as Symbicort or Spiriva are not cheap ($~80-90/month) but patients can only afford salbutamol MDI that is about $10. I have seen patients diabetes worsen due to lack of coverage. But this has gotten worse during COVID pandemic.
Those who support multipayors drug coverage system often quote this type of system will alleviate the cost burden on the public payer and allows for innovation or faster market access of innovative therapies, especially for the rare diseases. While this may be true, reliance on private insurance companies also complicates logistics for patients. Private insurance companies can decide when not to pay for an expensive drug anymore, or when to suggest a special authorization is required, at the drop of a dime. They bear no responsibilities to the sudden therapy interruption to the patient, as long as they are saving drug costs. Also with the loss of employment that we can see during the COVID pandemic, many patients have lost drug coverage. For those with Trillium drug coverage in Ontario, many don’t understand the concept of quarterly deductibles and when these deductibles will be met. In their eyes, they still don’t have “coverage”.
If we are to design a National Pharmacare program, we need a simple system that is patient-entered, that takes into considerations whether the vulnerable patient population or those with low health literacy skills or language barriers can access the program easily and more effortlessly.
I do agree that we need to move forward with the National Pharmacare Program. Now is the time. Thanks for this article.
Single-payer universal Pharmacare is a no-brainer. It has been shown over and over again to be the fairest, least expensive, and most efficient way to provide everyone with prescription drugs. Under the current system the insurance companies are useless middlemen. Once your doctor has prescribed a medicine you should be able to pick it up at the pharmacy and have it covered under the public plan just like doctors. Drug companies are able to charge absurdly high prices because the payers are hopelessly divided into over 100,000 plans and are unable to negotiate for reasonable prices. In addition universal public Pharmacare would allow for improved prescribing by doctors as practices and drugs could be reviewed and evaluated for best therapeutic effect.
Respectfully, I disagree that the only model right for Canada is public single payer. Absolutely, it would work, it would fit within medicare, and it would be the least expensive to administer. But we must also examine its feasibility, and whether there is any political appetite to implement it. Seventy-five years after it first publicly introduced this idea, the federal government has not acted.
To address your points, the number without any coverage is likely very small, although there are no complete or current data. Whether you have public or private insurance, the access mechanism is virtually identical and so are the cost control measures. It is also not a question of a single buyer driving lower prices. The Netherlands has half our population and its per capital costs for prescription drugs are half ours. Our ability to monitor and even incent better prescribing is also dependent on political will, but is independent of how we finance drug insurance. Germany has had a variety of incentives and penalties aimed at physician prescribing for several years, and it has had a mixed-finance, social insurance model for 120 years.
So the issues of inadequate and inequitable coverage remain, and we need to act for the sake of those who need better access. In short, if governments are unwilling to act, then there are others who can and should at least begin this national project.
The narrative of drug companies need to charge $x because it funds expensive research or subsidizes treatment for rare diseases needs to be changed. And we saw it change with COVID-19 vaccine costs. I think estimates are that is it 10% of what its “retail” cost would have been. The rights of research which is often subsidized by public dollars in universities and how that research is taken private and then how it is commercialized for profit, that whole value chain needs to be re-examined. This article proposes tackling the affordability problem by government action but maintain the foundation of what make drugs unaffordable and inaccessible. What I want to know is what is the most market efficient strategy.
I give these authors full credit for keeping the idea of national pharmacare alive. However, we need to get more creative. We talk and write about a public single payer drug plan, and have for decades, but it’s not happening. ‘There is nothing is more dangerous than an idea when you only have one.’
The challenge is how to reorganize the health care system to pay for universal drug insurance. Coverage depends on where you live or work, and patients pay too much here, more even than in the US. A single payer plan is not the only solution and we can glean from federal inaction there are still serious reservations about implementation. A major hurdle is F/P/T relations and provincial autonomy. A second is that cost models, including that done by the PBO, do not use realistic assumptions and so payers do not believe there are massive and immediate cost savings. A third reality is the existance of a robust and popular private drug insurance industry. In fact, private insurance has been the largest payer of prescription drugs since 2017 according to CIHI. Despite the added costs it entails, we can’t ignore that reality.
So how else can we make progress towards universal coverage? We should start with a national prescription drug strategy to integrate many scattered initiatives by F/P/T governments and private insurers and their employer clients. Negotiating a national standard for limiting out-of-pocket cost would bring down the affordability barrier. A strategy for drugs for rare diseases is long overdue. In the longer term, more investigation of an EU-type social drug insurance model could make this a viable solution because it includes a regulated private insurance component which spreads the cost burden beyond Covid-strained provincial budgets. (I understand the challenges of carving out drugs in a social insurance system but these can be addressed.)
The best approach is to consider more feasible ideas that address the biggest gaps. We need to work together to make it easy for governments to act and all our citizens to benefit.
Pharmacare is a worthwhile initiative. The racism trope in the headline was not required. It’s getting tiresome. This victim-oppressor, critical theory narrative will lead nowhere good. Stop it, please.
Says the privileged white person. Not surprising. Jeez.