I've written on this topic before several times but pharmacare keeps popping up during the lead up to the federal election on October 19. The political parties aren't talking about it much but others are.
One of the obstacles to creating a national pharmacare program in Canada is cost but an article that appeared in the CMAJ some months ago suggested billions of dollars in health care costs could be saved through such a plan. Others chimed in. It sounds so good.
But there are a few problems with the depth of this study.
In order to understand how billions of dollars in savings from a national pharmacare program are NOT possible, we need to understand several points.
1. The study looked backward not forward.
New medications associated with new screening tests and new biomarkers are on the horizon. Immunologics and biologics for chronic disease will not be curative but they will be expensive. New tests to assess who will benefit and who will not and new modalities for assessing cancer survivorship. It is not reasonable to exclude the costs of these medications and the costs of the tests and the costs of increasing chronic diseases from the assessment of potential cost savings.
2. National Pharmacare is intended as a sister program to Medicare in Canada.
While this may seem noble, our single payer health care system is not managing very well. Adding another big, bureaucratic system when we are already unable to meet demand in its predecessor does not make sense. Albeit that medicine is changing and more medications are taking the place of various procedures, the possibility of creating a "free" system for pharmacare will increase demand. We have seen the result of limitless "free" medical care with growing wait times and closures of hospitals to drive more care to the community where much of it remains unfunded.
What would be the result of a national pharmacare program that will be required to ration its availability? Which diseases would remain orphaned? Which would become new orphans? Which lobbying group would obtain coverage? Which political group will aim to benefit by promising what it can't later deliver?
3. Health care is a Complex System.
No matter how many times one puts "National" in front of a government program there can be no guarantee of the results. Making pharmacare a national program is an attempt to nudge more tax dollars from the federal government when the likelihood of savings is highly unlikely.
Once a national pharmacare program is in place it can't be taken back even if its costs soar to higher levels than expected. The supporters will say "Who could have known?"
Health care is like a balloon. Squeezing one area results in a bulge somewhere else. Blowing it up past its capacity results in a great big POP and structural failure.
While it is not possible to predict cost savings in such a system with so many variables beyond the actual cost of medication, it IS possible to predict that the demand for medications to be included in such a program will be ongoing. Political games will be played and effects will be felt elsewhere in the system...we just won't be able to predict where.
Does the unpredictability of such a system mean we should be doing nothing about creating a more universal system of pharmaceutical coverage?
No. It means that we should be looking at more reasonable ways to create coverage for the one in ten people who reportedly cannot afford their medications.
Instead of creating another complex bureaucratic system that will inevitably become politicized, let's look at the various programs that are working well to provide coverage for those in need.
4. A national pharmacare program requires provinces to relenquish power.
There are a multitude of provincial and territorial pharmaceutical plans in place to assist in medication coverage. Provinces hold the power when it comes to how to fund and how to manage publicly funded medications.
Will the provinces and territories accept that a national pharmacare program will define what they will have to provide? When it comes to provincial medical care provision, the provinces tend to show their disdain for federal direction. Sure, the provinces want more federal funding but when it comes down to directing the funds to their final destination, historically it appears that the provinces resist federal directives--happy to take the money, unhappy to be told how to spend it. And the federal government has limited tools with which to force the provinces to comply.
Will the provinces be willing to give up their power to the federal government? I doubt it.
5. If a national pharmacare program were to emerge, what happens to the ability of citizens to access private drug plans? Would they still be affordable or would they be so reduced in capability that their offerings would either be redundant or limited in nature?
Nothing in a complex system happens in isolation. Creating a national pharmacare program seems simple. It is far from it.
If we lose the ability of private insurance plans to cover certain medications what happens when a national pharmacare program determines that the cost of a certain drug is beyond funding? What happens when there is no significant private option to turn to?
We've seen this before. The single payer health care system has become monopolistic and denies patients care based on cost, availability, and rationing by other means.
What happens to patients when they are promised government pharmaceutical coverage but then the promises are broken? Sound familiar?
A national pharmacare program is not a solution. Instead, let us enhance the coverage for the one in ten Canadians who say they are unable to afford their medications. Hoping for billions in savings from a National Pharmacare program is unrealistic and misleading.