Dr. Eric Hoskins, Chair of the Advisory Council on the Implementation of National Pharmacare, presented his final report on June 12.
Sean Kilpatrick / THE CANADIAN PRESS
Should we replace all existing private and public drug insurance plans and set up a new government bureaucracy?The recent report on pharmacare by Dr. Eric Hoskins and his advisory council addresses a definite need to expand drug coverage to include all Canadians. However, it avoids certain rather important issues.Some 10 to 20 per cent of Canadians are uninsured or underinsured for necessary prescription drugs; the rest are covered by a patchwork of public and private plans. The problem is exacerbated by the aging population and the greater number of part-time workers with few drug benefits. Drug costs are rapidly increasing, generic drug prices in Canada are the third-highest in the world. Some drugs in Canada are 10 times as expensive as in New Zealand.Some 10 to 20 per cent of Canadians are uninsured or underinsured for necessary prescription drugs; the rest are covered by a patchwork of public and private plans.The Hoskins report lists six “Comparator Countries.” In virtually all, health delivery is national. However, the Canadian constitution requires that health be under provincial or territorial jurisdiction. Hoskins acknowledges that it may take some time before all provinces and territories are prepared to opt in. This certainly applies to Quebec, which already has a comprehensive, universal drug plan and its own agency, INESSS, to evaluate drugs This will undermine the goal of mirroring all of the principles in the Canada Health Act.Hoskins states, “The council recommends the federal government enshrine the principles and national standard of pharmacare in federal legislation separate and distinct from the Canada Health Act.” Most importantly, “We are also concerned that amending the Canada Health Act might lead to pressure to make other changes.”Why does he wish to keep his program separate? He recommends modest user fees and also that private insurers be allowed to provide private coverage for copayments, as well as for drugs not on the national formulary. He neglects to mention that all of the Comparator Countries also have a blended public/private health delivery system. These are kept fiscally sustainable with shorter wait times thanks to modest user fees and private coverage of some physician services also covered by the public system – all prohibited by the Canada Health Act.Federal governments have refused to enforce all of the Canada Health Act. Quebecers still lack portable medical benefits, and must usually pay out-of-province MDs directly. Except for Prince Edward Island and the three territories, all provinces have been paying only a small portion of the required amount for hospital care outside of Canada. What assurance is there then that a national pharmacare program would be fairly and adequately policed?When the CHA was passed in 1984, Ottawa promised to pay half of total health costs, but its share is now down to about 21 per cent. Hoskins recognizes that provinces and territories demand secure federal funding before signing a new agreement, i.e. “One party should not be able to make unilateral changes to the arrangement.”Related
How to proceed? First, “filling the gaps of drug coverage” should be implemented soon at an estimated initial cost of $3.5 billion annually. Very expensive drugs for rare diseases should be covered for all Canadians. There should be tighter policing of rebates by generic drug companies to pharmacies.What about persons already covered by private and public insurance plans?Because of bulk-purchasing by the Pan-Canadian Pharmaceutical Alliance, drug prices would supposedly drop, resulting in a savings of $100 per year in drug premiums and for businesses, $750 annually per employee (total of $15 billion). However, the marginal cost to the federal government would be at least $15.3 billion annually by 2027. This at a time when the federal deficit is already about $20 billion per year.Hoskins is vague on funding. He permits businesses now relieved of costly drug plans to keep the money, possibly to be returned as other benefits such as physiotherapy, vision and hearing care, etc. Instead, he should recoup most of these dollars so as to reduce the federal debt or tax increases otherwise required to pay for his program.To help fund pharmacare, Ottawa should also study and implement ideas from successful blended systems in the Comparative Countries. It should then amend and modernize much of the Canada Health Act. Both Hoskins’ report and a total reassessment – after 35 years – of the Canada Health Act should be on the agenda when the premiers and territorial leaders meet in Saskatoon from July 9 to 11 for the Council of the Federation.Dr. Charles S. Shaver graduated from Princeton University and Johns Hopkins School of Medicine. He is past chair of the Section on General Internal Medicine of the Ontario Medical Association. These views are his own.