A recent CMAJ article by UBC's Steve Morgan PhD, and Danielle Martin MD and others entitled "Estimated cost of universal public coverage of prescription drugs in Canada" is making the rounds.
The Toronto Star picked this up and is now spreading the word about how affordable a National Pharmacare program could be stating potential savings of $7.3 Billion. This is misleading to say the least.
The abstract from the CMAJ publication includes as background that,
"With the exception of Canada, all countries with universal health insurance systems provide universal coverage of prescription drugs."
What the authors conveniently leave out is that Canada is the only developed country in the world that has a single payer health care system for medically necessary care. It is no surprise that it does not have universal public drug coverage. It can't even afford to meet demand for what it has already created let alone add other programs. The "game changer" CMAJ study conclusion is flawed on multiple levels.
First, let us acknowledge that despite many tens of billions of additional federal dollars in recent years, timely access to care in Canada is ranked last in comparison to many developed countries. The better performing systems are from countries with Hybrid systems that have universal medical care through a combination of private and public funding mechanisms and which also have publicly funded pharmacare programs and even dental and eye care.
Until Canada allows provincial health systems to evolve to hybrid systems using combination funding mechanisms, a National Pharmacare program is unaffordable, not because of the cost of the medication necessarily but because of the burden of single payer health care delivery.
It is not unusual for government programs to exceed their anticipated costs and for any savings promised to be elusive. We can look at the cost of Canada's former Long Gun Registry that was anticipated to cost 2 million and which reached 2 billion. Look at the cost of eHealth in Ontario and Canada to understand how programs that start out with predicted costs begin to balloon and cost many billions more than anticipated without even being completed.
Creating an ongoing National Pharmacare program that creates dependency but that can then have no end is a recipe for creating costs that are not affordable despite what some economists and well meaning physicians say. Once it is created, there can be no going back. Unlike the Long Gun Registry, closing down a pharmacare program and cutting off medication to patients that have grown to expect it is a very different situation.
Look also to Quebec's experience with its publicly funded pharma program. Despite touting its universal public drug coverage for its citizens, Quebec has robbed its medical system to cover its pharmaceuticals. While the shift is not transparently done, it is at least clear that Quebec has difficulty affording access to quality medical care as its citizens swarm Ontario hospitals and MDs for access to care. There are always trade offs.
Other programs in Quebec were expected to save dollars by creating public coverage but did not. Several years ago a CMAJ article suggested cost savings from a publicly funded In-Vitro Fertilization program and yet cost savings did not materialize. In fact, the popularity of this program soared and costs with it so much so that recently Quebec women were encouraged to go about pregnancy "the natural way" with focus for at least three years!
The accuracy of predictions by the CMAJ and some well-meaning medical doctors is suspect. One Toronto-based MD wrote a few years ago that maintaining Canada's single payer system was no problem, our rising GDP was going to save the day. This is a sober reminder that not all of what we believe is predictable is truly predictable. It is a cautionary example of how a more cautious and thoughtful approach to health care is required so that politicians do not promise what cannot be delivered despite the best of intentions. Creating a dependency on entities that cannot be sustained is irresponsible.
Dr Danielle Martin, one of the authors of the study claims that it is with "certainty" that specific claims of cost savings can be made. I caution Dr Martin that in a world that is increasingly unpredictable, speaking in certainties may sound confident but can also be ultimately misleading.
However, there are many other issues with the report that should be identified.
The authors of this study may defend their report citing that savings can be had in a National Pharmacare program through the following mechanisms:
1. Increased use of Generic medications
2. Lower Generic prices generated through bulk purchasing
3. Lower Brand Name prices through economies of scale in price negotiations.
These premises are flawed.
Consider the drug shortages that have resulted in part from governments favouring generic drugs. The pharmaceutical industry is in upheaval responding to new realities in different ways by altering its assembly lines and looking to rebalance profitability. Only people with little insight into complex systems would believe that prices can be driven down through bulk purchases without some resulting compensatory response.
Look at recent concerns over generic drug manufacturer quality issues to understand where this kind of bulk buying will lead us. A National Pharmacare program that relies on "best prices" has potential to also rely on lower quality products without the choice that patients currently have. It also has the potential to reduce access to brand name medications which in turn creates changes in the pharmaceutical industry that are unpredictable. What effect on production will occur? What shortages will result? It's anybody's guess.
One of the other major flaws with this report is that it uses past information to predict the future. This may seem like a standard approach to health economists or to people who do not study major scientific and medical changes such as Genomics or Epigenetics but anticipating future developments is important to understanding the viability of any potential National Pharmacare program. Although specifics may not be predictable, it is clear to see that on the horizon there are many new life altering and life saving drugs. It is arguable that this is the very reason why a National Pharmacare program is needed but until economic conditions have improved, assuring the viability and sustainability of such a program is dubious at best despite the claims of cost savings in the CMAJ study.
It must be noted that many more expensive medications for rare diseases are in the pharmaceutical pipeline. Expensive immunologics and biologics are being developed and have promise for many people. Adding these to many new and expensive medications for cancer as a chronic disease and medications for age related diseases such as macular degeneration, it will be difficult to avoid the lobbying for coverage of more and more medications.
Once again, we will have created a program that creates dependency on public funding and it will distort access to medication as private options become limited or are passed up by patients. A National Pharmacare program that identifies medications it will include based on cost savings will have repercussions when patients are denied coverage due to cost and who have not purchased private coverage, much the way the public health care system fails patients who were led to depend on it and then who are denied access to the care or procedure based on excessive cost to government.
It is not uncommon for patients who have been denied public coverage of a medication for their cancer to have it funded through their private drug plan. A National Pharmacare program has potential to create an expectation by patients that their pharmaceutical needs will be met. This is as unfair as what has been created in our government funded health care system. Funded care may exist, but it may not exist for you despite the fact that you have paid into the system.
Now is not the time for a National Pharmacare program. The CMAJ study makes assumptions that future pharmaceutical demand can be assessed in a snap shot of today and of previous years. This is simply not the case. The affordability of universal public coverage of prescription drugs is currently not possible despite the best efforts of well-meaning individuals to present it as such. Once there is a Hybrid system for medically necessary care in Canada, this discussion could be revisited.