National pharmacare: Why a one-size-fits-all approach misses the mark

Posted on November 29, 2018

By Sarah Lussier Hoskyn

In the national pharmacare debate, there is a strong push for a single payer, publicly-funded system. Prominent academics have backed this approach, arguing that a national, comprehensive program – as opposed to today’s mixed model of government drug programs and private insurance – is the best way to make medicines more affordable for all Canadians. But as two reports published last week illustrate, those who struggle the most to afford medicines tend to fall into two distinct populations, and face very different challenges. A simple one-size-fits-all solution risks addressing one group of Canadians at the expense of another – or worse, helping neither.

According to the recent report from the Canadian Institute for Health Information (CIHI), healthcare costs across the board are rising. The main driver of drug cost growth, as for all other health spending, is the growing number of Canadians suffering from chronic disease. This group is made up of two key distinct populations. The first is a large beneficiary population (75 per cent) that uses low-cost drugs and represent a smaller share of total plan spending, while the second is a much smaller proportion of beneficiaries (5.5 per cent) who uses higher cost drugs and represents a disproportionate share of total plan spending.

In a study published in CMAJ last week, UBC Professor Michael Law and his team also found that the majority of the 2.5 per cent of Canadians who borrowed money to pay for medicines use low-cost drugs. The study showed that these are younger Canadians, have several chronic health issues, and have low disposable income – increasing the likelihood for them to forego other basic necessities such as food or rent in order to pay for their drugs, despite their relatively low out-of-pocket costs.

In addition to the struggle to pay for medicines, these vulnerable Canadians face a number of other challenges such as housing and food insecurity, poorer access to employment opportunities and to community-based, patient-centred health care. Given this reality, pharmacare options that help address the needs of those who have fallen through the cracks in our current system should be prioritized.

As for the second group of Canadians highlighted in the CIHI report, those who require higher cost medicines, their struggle to pay for out-of-pocket costs stem from very different circumstances. These Canadians suffer from complex and sometimes rare diseases which require specialty treatments that are very expensive, and the patient in some situations is forced to shoulder a substantial part of the cost sharing load with their public drug plan or their private insurance plan. Governments, private insurers and the innovative medicines industry worldwide are grappling with how to address the high costs of these medicines for the patients that need them. In Canada, this issue is an opportunity for immediate federal-provincial-territorial cooperation and engagement with the industry. Addressing the problem of high cost and rare disease drugs will require better planning and integration of Canada’s health systems.

There is no doubt that some Canadians struggle to afford medicines and that there is a role government can play in addressing this problem. But as we learn more about the underlying reasons behind this struggle, one single solution cannot solve two very different problems.

Addressing the issue of high cost, rare disease drugs will not help those low-income Canadians who need help in accessing low cost medicines for chronic diseases. Similarly, a national pharmacare program that harmonizes coverage downward to the lowest common denominator will not help those who require expensive treatments to relieve their suffering.

If the goal is to create better health outcomes for all patients, a targeted approach to national pharmacare is the most practical and effective way to improve quality of coverage by addressing out-of-pocket costs for these two distinct populations.

All Canadians should have adequate and timely access to the choice of medicines they need to maintain and improve their health, regardless of income, age, disease or postal code. Our industry stands ready to work with governments and other stakeholders to implement targeted funding models and plan designs that help vulnerable Canadians who lack the means to afford their medications.

Sarah Lussier-Hoskyn is a Senior Analyst at Innovative Medicines Canada.

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