National Pharmacare in Canada: 2019 or Bust?

It is the Canadian public policy issue that rears its head with regularity, never achieving much more than discussion, and yet never going away entirely. The issue is pharmacare, and once again it is back for discussion among academics and policy-makers, and once again it looks like the discussions will not go anywhere anytime soon. The proposal for a publicly funded pharmaceuticalcoverage plan is frequently on the table in Canada, but it still is not in the cards. Canada is the only member country of the Organisation for Economic Cooperation and Development (OECD) with a public health-care system that does not include coverage for pharmaceuticals. As a result, Canada spends markedly less public money than the OECD average on pharmaceuticals (42 per cent of drug payments are public funds, versus the average 70 per cent), although it also spends more than the OECD average on hospitals and doctor visits. Advocates for an expansion of the publicly funded medicare system to include prescription medication note that it has become common for some lower-income Canadians who lack private drug insurance to leave prescriptions unfilled due to the cost, or will miss doses. This affordability problem for lower-income Canadians appears to be getting more serious. However, while Canadians seem to express support for the idea of pharmacare when asked about it in surveys, it remains well behind a list of other improvements to the health-care system that they consider to be of higher priority. They are more interested in improving access and wait times, and they are more concerned about the sustainability of the current system given the increased demands of the aging population. Both employers and workers, meanwhile, also support the existing model of employer-provided drug plans. Perhaps the biggest obstacle for champions of pharmacare, however, is that the term can mean so many different things to different people. There is virtually no consensus on what would even be the appropriate Canadian system, particularly in light of how significant a factor private coverage already is in Canada. A pharmacare plan might include anything from the drastic step of eliminating all private coverage and subsidizing all prescription medicine for all patients regardless of income, to a much narrower program that covers some portion of the cost of only some drugs, for some income levels. There are also countless different possible models between those two. The matter of how much each level of government, provincial/territorial or federal, would be responsible for funding drugs is a whole other, rather thorny matter. The timing of this latest discussion about pharmacare — stimulated mainly by recent proposals and fuelled by the success of the pan-Canadian Pharmaceutical Alliance in negotiating better bulk drug prices — is also particularly unfavourable. There has been a sudden shift in the dynamic between the federal government and the provinces, where before premiers stood together and collectively bargained with the federal government for health-care funding, but recently splintered and are now making individual deals (while Quebec continues to insist that it must have complete freedom from Ottawa to design its own health system). The difficult fiscal situation across Canada, with so many governments running up debts, would also seem to make it highly unlikely that there will be much enthusiasm for embarking on a new and sizeable social program costing billions of dollars a year. Lacking enough leaders to passionately champion it, and with a public generally uninterested and very unclear on what a national pharmacare program would even entail, it seems that the current discussion about implementing a pharmacare system may come to a stall, like so many discussions before it.