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Xxiv poem by Elizabeth Barrett Browning. As the box shows, the studies did not all recommend the same model for pharmacare but they all concluded some form of it would result in better health for Canadians and lower costs for families, employers and governments.

If you think being an electrician keeps you busy, try being one who has to watch his diet, exertion level, hydration and sugar levels, all at the same time as wiring a building—safely.

There are often long hours, long days and long weeks. Not ideal conditions for a diabetic. I could see their point, but it was a hard pill to swallow pun intended.

Is it ideal? No way! Look, I work hard, I do my bit. Supreme Court Justice Emmett Hall was appointed to lead the commission in and his final report laid the groundwork for universal, public health insurance introduced through the Medical Care Act in The commission also called for the creation of a national agency to negotiate prices, decide what drugs should be covered, monitor prescribing and drug safety and provide objective information about medicine to patients and health care providers.

Chaired by Senator Michael Kirby, the committee looked at the federal role in health care, focused mainly on supply, human resources and the need for greater competition.

On issues related to prescription drug coverage, it said that no Canadian should suffer undue financial hardship because of the cost of prescription drugs.

The committee recommended introducing catastrophic coverage and said the federal government should cover 90 per cent of the cost of the program.

It also called for the federal government to work closely with the provinces and territories to establish a single national formulary.

The House of Commons Standing Committee on Health heard from expert witnesses on pharmacare and commissioned a study by the Office of the Parliamentary Budget Officer to examine its potential for cost savings.

To ensure all Canadians have affordable access to prescription drugs, the committee recommended establishing a universal, single-payer, public national pharmacare program by expanding the Canada Health Act to include prescription drugs dispensed outside of hospitals as an insured service.

Each of these studies also said that national pharmacare should be consistent with the principles and values of the public medicare system, regardless of the specific model each study recommended.

With that consensus, with the obvious need and the strong support from Canadians, why do we not have a system of national pharmacare?

The answer to that goes back to the very beginning of universal, publicly funded health insurance commonly called medicare in Canada.

The idea of universal, public coverage for health care started gaining popularity in Canada after the Great Depression hit in , when progressive organizations and political parties began promoting the idea.

Endnote 6 In , Saskatchewan was the first province to introduce universal public hospital insurance including coverage for drugs administered in hospitals , with British Columbia and Alberta following a few years later.

In , the federal government passed the Hospital Insurance and Diagnostic Services Act , which offered to share provincial and territorial costs for hospital and diagnostic services, provided that provincial governments met certain conditions.

Within four years, all provinces and territories were providing residents with access to hospital services at no charge. In , Saskatchewan again led the country by expanding public coverage to include physician services.

The move was fiercely resisted by opposition politicians and doctors who went on strike , foreshadowing the reactions of doctors and some politicians in every province in the years to come as medicare was gradually introduced and expanded.

Endnote 7 Despite that powerful opposition, public support for medicare remained strong. We believe that the only practical and effective way of doing this is through a universal, prepaid, government-sponsored scheme.

The establishment of public insurance for hospital and physician services across the country irrevocably cemented the foundational concepts of Canadian health care—universal access, public administration and zero cost at the point of care.

In , the Canada Health Act further codified these ideas in its five principles—that health care should be publicly administered, accessible to all, comprehensive, universal and portable.

Neither the Medical Care Act nor the Canada Health Act , however, included coverage of medicines prescribed outside of hospitals.

When medicare was introduced in the s, prescription medicines played an important but much more limited role in health care, with a range of fairly inexpensive drugs used to treat common conditions.

Government officials decided to focus on the most important and expensive components of health care at the time—hospitals and physician services.

Although prescription medicines were intended to be added at a later date, changing economic conditions, shifting priorities, and the ups and downs of federal-provincial-territorial relations sidetracked efforts to bring about national pharmacare.

In the absence of pharmacare, provinces and territories developed their own drug plans. Most were designed for vulnerable groups, such as people on social assistance and seniors.

At the same time, employers began offering health benefits including prescription drugs, vision and dental care , as a way to attract and retain talent in a competitive labour market.

The more than drug plans run by federal, provincial and territorial governments are aimed at improving access to prescription medicines primarily for people who might otherwise not be able to afford them.

Each plan is different, but often tailored for specific groups such as seniors, children, those with low incomes, or people with serious medical conditions.

The federal government provides drug coverage to registered First Nations Footnote i and recognized Inuit populations, federal inmates, members of the Canadian forces, veterans, resettled refugees and refugee claimants.

In addition to those public plans, all provinces have a form of safety net coverage for their residents. The most common form, often called catastrophic coverage, protects people from the financial catastrophes very high prescription drug costs can trigger.

British Columbia, Saskatchewan, Manitoba, Ontario, Nova Scotia, Prince Edward Island and Newfoundland and Labrador offer catastrophic coverage, which people become eligible for when their total drug costs exceed a certain percentage of household income their deductible.

Some provinces have more generous deductibles than others. Safety net programs in other provinces are based on premiums. In Alberta and New Brunswick any resident has the option of enrolling in public drug coverage by paying a premium.

Quebec is the only Canadian jurisdiction that has achieved universal drug coverage and it did so by making drug insurance mandatory for all residents.

Residents who are not eligible for private insurance through their employer or occupation are required to enrol in, and pay premiums for, the provincial drug plan some vulnerable groups, such as low-income seniors, are exempted from paying premiums.

While the territories do not offer broad-based safety net programs, many residents are covered under the federal Non-Insured Health Benefits Program, which provides drug coverage to over , registered First Nations and recognized Inuit across Canada.

The lack of universal public drug coverage in Canada has created a market for private drug coverage. Private drug plans are generally intended to attract workers and support workplace productivity, not serve as social safety nets.

Most private plans have open formularies—that is, the lists of drugs they will pay for includes almost every medication Health Canada approves for use, regardless of whether they are more or less effective, or cost more or less, than other available drugs.

This gives physicians and patients access to the broadest possible range of treatments, but also can lead towasteful spending because there is little incentive for patients or providers to choose a lower cost, equally effective therapy.

For their part, public formularies emphasize effectiveness and value for money. Source: Law, M. Available from Health Canada by request.

Source: Law, M Source: Law, Michael. Linking drug coverage to employment presents another potential problem—it could limit job choices for people.

Notably, governments are some of the biggest sponsors of private drug insurance plans. Most public sector workers at the federal, provincial, territorial and municipal levels—including those working in health, education, and social services—have prescription drug coverage as a benefit of employment.

This means that as many as 30 per cent of all private plan beneficiaries are public sector employees whose benefits are delivered by private health insurers but paid from general tax revenues.

However, as concerned as governments are about runaway prescription drug costs, these plans are more expensive and inefficient than public drug plans.

I take common, but costly, medications for asthma and ADHD. Now I use our public provincial pharmacare program to cover the majority of my medications as it is still affordable.

At the end of each year, I calculate how to deal with health costs for the next year: is it cheaper for me to pay the provincial deductible and medical expenses out of pocket, or should I get a private medical plan?

With luck and continued work my income will increase, but so will my deductible, to the point where I will be paying the full cost out of pocket.

In our unstable job market, why do we continue to tether drug insurance to stable employment? Where does that leave the creatives and entrepreneurs who just happen to have a chronic illness?

How we treat disease is evolving rapidly as pharmaceutical companies push their science further and further in search of new treatments and cures.

The landscape of drugs available on the Canadian market is crowded and complex, and pharmaceutical companies continue to introduce new and specialized products at a rapid rate.

Not all drugs live up to initial expectations and others become outdated quickly as new treatments for the same condition are developed.

Newly launched drugs can generate excitement, but some offer little benefit over older, lower cost alternatives.

Annual Report It is not just research and development that makes these new specialty drugs so expensive. Many new medications are not just another pill to be dispensed at the pharmacy and taken at home.

Often, they are given to patients by injection or infusion and require special storage and handling, and the patients who take them need close monitoring throughout their treatment, all of which adds costs.

Many of these new drugs are biologics, which are made from living cells or organisms using biotechnology many new cancer drugs are biologics, as well as drugs used to treat rheumatoid arthritis, irritable bowel disease and psoriasis, among others.

They are harder to develop and manufacture than traditional chemical drugs. As well, pharmaceutical companies are developing a growing number of drugs for rare diseases.

These products are often the only treatment available for conditions that may be seriously debilitating or life-threatening, but the cost of development, small numbers of patients and few treatment options combine to drive up costs.

At the same time, some new and expensive specialty drugs are for relatively common conditions, such as migraines, where demand and therefore spending could be high.

These new drugs can be life-changing for patients, but they are often staggeringly expensive. Today, top-selling brand name drugs often cost thousands or tens of thousands of dollars per year.

Endnote 9 It does not take long, in the face of such overwhelming costs, to realize we can no longer continue with a fragmented, expensive, out-dated and poorly thought-out approach to funding such a vital element of health care.

A system that depends on every player assuming someone else will find money somehow instead of planning and organizing to ensure needs are met cannot serve the needs of Canadians in the future, or even in the short run.

While it was a relief to finally know what was wrong, our world took a very sudden, complex and traumatic turn. He takes 25 medications daily to deal with symptoms.

And when you add up the copayments on 25 medications…sigh. Myself, my son and my other children moved to the city to be closer to appointments and clinics, while my husband had to stay for his job.

I had to quit mine as it was impossible to juggle it with all of the appointments and my family. My faith has been my touchstone throughout this, and I am thankful for it, my family and friends.

I know if you were in my position, I would not hesitate. In the absence of national pharmacare, a patchwork of public and private drug plans has evolved in Canada.

This fragmented system is not equipped to handle the increasingly complex and expensive medications surging onto the market and is failing Canadians in a number of fundamental ways.

The most profoundly unfair result of not having national pharmacare is that while the majority of Canadians have at least some insurance for prescription medication, many people have none at all.

Endnote 11 This likely reflects both the uninsured people who have no coverage and the underinsured who have inadequate coverage.

Some of the difference in numbers may be due to catastrophic coverage. In that situation, coverage may be more theoretical than real.

One study found that 4. Endnote 12 So while only a small proportion of Canadians are actually completely uninsured, a much greater number are underinsured—the two together probably make up 20 per cent of the population—leaving 1 in 5 Canadians struggling to pay for their prescription medications each year.

A substantial proportion of underinsured Canadians have some form of private insurance. But premiums, deductibles, copayments, coinsurance and annual and lifetime limits mean that out of pocket costs can still be high.

Endnote In this hypothetical example, we present Nadia, a year-old single mother with two children. She and her family have prescriptions for gastric reflux, anxiety, birth control, asthma, attention deficit hyperactivity disorder and the occasional ear infection.

With public drug coverage, Nadia would have to pay different amounts, depending on where she lived in Canada. For those Canadians eligible for government public drug benefits, there are differences in coverage within and across provinces.

Federal, provincial and territorial drug insurance plans have broadly similar goals—generally, protecting the health of vulnerable people—and a review by the Patented Medicine Prices Review Board found that for the majority of drug classes, the public drug programs all provided access to equivalent though not identical drugs.

Endnote 14 But differences in who is covered, how drugs are funded, the amount of out of pocket costs and the rules to be followed are all contrary to the idea that all Canadians should have equal access to health care—based on need, not their ability to pay or where they live.

One province may require doctors to get authorization from the plan before prescribing very expensive drugs or for drugs with a high potential for misuse, while other provinces have no such barriers.

He was recently diagnosed with advanced lung cancer. One of the most common arguments against pharmacare is that most Canadians have private drug insurance.

Also, prescription drug coverage is not evenly distributed among working people—according to the Wellesley Institute, 73 per cent of full-time employees report having medical benefit coverage while only 27 per cent of part-time employees do.

Endnote 17 Accessing private drug coverage can also be a challenge for the many Canadians who are self-employed or work temporary jobs, such as contract or casual employment.

Endnote 18 That means women, people with low incomes and young people—who are all more likely to work in part-time or contract positions—are often left without drug coverage, simply because of the type of work they do.

The nature of work has changed rapidly over the past two decades. Changing business practices and the emerging gig economy—where more people are working temporary contracts or are self-employed—are reducing opportunities for stable, full-time work.

As a consequence, a growing number of Canadians are finding themselves without access to workplace drug benefits. Implementing national pharmacare would help ensure that all Canadians, regardless of what kind of job they have, enjoy fair access to prescription drug coverage now and into the future.

In a national survey, 23 per cent of Canadians told Angus Reid they or someone in their household had not taken their medicines as prescribed in the last year because they were too expensive.

Endnote 21 A recent study found almost 1 million Canadians had cut spending on food and heat to pay for medication, Endnote 22 while another found 2.

Endnote 23 Cost-related non-adherence not taking a prescription properly because of its cost is two to five times higher in Canada than in comparable countries with universal pharmacare.

Of those who told the Canadian Community Health Survey they could not afford one or more of their prescriptions, about 38 per cent had private insurance coverage and 21 per cent had public coverage.

Endnote 26 Canadian and international research shows that kind of direct charge makes people less likely to take prescribed drugs. Endnote 27 And the costs that people with private plans pay—between copays and deductibles—is increasing, from 10 per cent of their drug costs in to 15 per cent in Endnote 28 As well, the overall share of private health insurance premiums paid by employees has risen rapidly from 26 per cent in to 40 per cent in Source: Statistics Canada.

Canadian Survey of Household Spending, Table Another cost patients face is caused by some private and public plans not starting coverage until patients have paid a certain amount of their drug costs themselves, which is called a deductible.

Several studies of the impact of out of pocket charges on Canadian seniors and people on social assistance found that more of them were admitted to hospitals and nursing homes after copayments were introduced; death rates increased as well.

Endnote 33 , Endnote 34 A study found approximately one-quarter of Canadians who said drug costs were an issue for them visited a physician, emergency room or hospital more than they would have otherwise.

Endnote 35 Researchers recently looked at the impact that removing out of pocket costs for medications would have on just three diseases—diabetes, cardiovascular disease and chronic respiratory conditions.

Endnote 37 Severe health problems caused by missed medication may eventually force people to stop working altogether.

Diabetes management has always been a team effort between my Mom and me. My diabetes has always been hard on my family and I felt guilty growing up.

I know better, but I often reuse my syringes, skip tests or hold off on an injection a little longer to make my insulin last.

To add insult to injury, I just found out that I have inherited sleep apnea. With needles, test strips and insulin, it still really adds up.

My condition will never go away. With the economy the way it is, I feel the likelihood of me finding a good job with benefits is pretty low. With a pre-existing condition that will deny me private coverage, how will I cope?

There have been steep increases in spending on prescription drugs used outside hospital in recent years. However, an increasing number of the drugs developed for use outside hospital are expensive specialty drugs that are steadily driving up the price of treatment.

Since , the average annual cost of specialty drugs has increased nearly 13 per cent per year. Endnote 38 The average cost of all drugs has increased by 7.

High-cost specialty drugs are not the only reason spending has increased: growing rates of chronic disease—such as diabetes and chronic obstructive pulmonary disease COPD —have contributed too.

Endnote 41 Furthermore, those costs are projected to grow by about 6. Some employers try to manage rising drug costs by trimming wages and other employee benefits, or by encouraging employees to shop at less expensive pharmacies.

An increasingly prevalent way to contain costs is to cap the amount of prescription drug benefits a plan member and their family can receive, either annually or over a lifetime.

From to , the number of private plan members with an annual or lifetime maximum on their drug coverage grew by around 40 per cent so that today more than a quarter of private plan members have capped coverage.

Endnote 42 Employees who reach their plan maximum pay for additional costs out of their own pocket or may move on to a public drug program if they are eligible.

This trend to capping benefits is expected to accelerate as drug costs continue to climb. Pierre and Laila are a working couple in their forties.

Pierre drives for a local moving company and Laila works at a community centre. Laila is taking several prescription drugs for ulcerative colitis, one of which is a high-cost biologic drug.

Prognosis and survival are determined by sorting through a slew of predictive factors; how you respond to treatment is as varied as there are patients.

Luckily there are some very good treatment options available. They are life-changing, but staggeringly expensive. The carrier decided to boost the premiums for the coming year.

He was displeased. Unaware that I was the patient, the president grumbled to my spouse about ferreting out who this person was, not knowing he was speaking to the very partner.

Thankfully, my husband is working again, but we worry that it may happen again. Senior management at this company does display empathy to employees and their families.

We hope the sentiment lasts! How is it in a country like Canada that employers seem to have the unfettered right to fire someone due to an illness in the family?

There are other reasons private drug plans are looking less sustainable. Unlike public plans, which tend to fund only proven, cost-effective drugs, private plans have traditionally paid for nearly every drug approved by Health Canada, regardless of effectiveness or the value for money it offers.

Private plans are concerned that expensive new drugs, including biologics and drugs for cancer, will drive costs to levels companies will not be able to afford.

Endnote 43 To counter the impact of rising drug costs, some private insurers are starting to limit the selection of drugs they will pay for, or raising premiums.

According to the Canadian Life and Health Insurance Association, premiums for extended health benefits grew at an annual rate of 3.

Provincial and territorial governments are also struggling to cope with rising drug costs. These cost pressures have the potential to undermine the ability of provincial and territorial governments to provide services within and beyond health care, such as education and infrastructure.

In a recent report, the Parliamentary Budget Officer found health care costs may threaten provincial and territorial government finances over the long term.

Endnote 45 Rising drug costs are forcing provinces and territories to make difficult decisions about who is eligible for their programs and which drugs they will cover.

Source: Canadian Institute for Health Information. All countries struggle with the rising cost of drugs, but in Canada paid the third highest prices for brand name drugs and the seventh highest prices for generic drugs among the 34 countries of the OECD.

There are a number of reasons we pay more than other countries; one of the most important is buying power.

In Canada, having thousands of different public and private insurance plans dilutes our negotiating power with global pharmaceutical firms.

In an effort to counteract that, the provinces and territories established the pan-Canadian Pharmaceutical Alliance pCPA in to negotiate jointly on drug pricing and supply arrangements such as maximum expenditure agreements on behalf of participating public drug plans the federal government joined in Other OECD countries also operate more efficiently when it comes to approving new drugs and managing coverage for them.

Many have single national agencies or several closely-related organizations to manage medication approval and coverage.

In Canada, however, the process that takes a drug from the research lab to the medicine chest is complex, decentralized, costly and slow, as shown in Figure Another factor that reduces the value Canadians get for the money they spend on prescriptions is the inefficiency of a mixed system.

Administration costs are generally three times higher in the private sector than the public sector, and that gap has widened over time.

In , administration accounted for 2. Since then, the public sector share gradually declined to 1. Endnote 47 Between these higher administrative costs and the amount kept as profits, private insurance adds considerable costs to an already expensive sector.

The fractured approach to prescription drug coverage drives up costs in another way: it gets in the way of gathering data needed to deliver good care and plan for an efficient health system.

The evidence is clear. Our current approach to funding and delivering prescription drugs is failing Canadians. It is unfair because it leaves 1 in 5 Canadians behind and exposed to unaffordable drug costs and poorer health outcomes.

It is one of the costliest systems in the world in per capita terms and is increasingly unsustainable in the face of a surge of new high-cost drugs coming on the market.

It does not deliver value for money for taxpayers, patients, employees and employers that fund the system. The bottom line is that Canada needs a new plan: a plan that is fair, affordable, sustainable and delivers better value for money for Canadians.

Before the council could recommend the best approach for Canada, it was essential we study how pharmacare works around the world. In Canada, as Chapter 2 described, the provinces and territories all offer drug insurance programs aimed at certain residents see Annex 4 , often including some variation of catastrophic coverage, alongside a separate private drug insurance system.

No other country approaches pharmacare in this way. Instead, most countries with universal health care systems include prescription drugs in their insured services along with hospital treatment, physician care and often a range of other health services.

Australia, New Zealand and the United Kingdom all fund universal public insurance to cover the cost of prescription drugs for their citizens, without deductibles and with limited or no copayments for eligible prescription drugs.

Residents of these countries can also purchase complementary private insurance for things not covered by their universal public health insurance.

These systems are all financed through general tax revenues. Through their progressive taxation systems, the cost of care is shared among all members of society according to their means—the wealthy help to pay for services for the poor, and the healthy help to pay for the care of those who are ill.

In France, Germany and the Netherlands, the law requires residents to buy health insurance, including drug coverage, from insurers that are primarily not-for-profit; it must meet standards set by the government.

In France and Germany, individuals are required to make modest copayments for their prescriptions. Residents of these countries can also purchase complementary private insurance for things not covered by their statutory health insurance.

We are already spending tens of billions of dollars on medicines. Canadians pay for prescription drugs through their taxes, through their premiums, through their wages and then they pay some more, when they reach into their pockets to cover their copayments and deductibles.

This scattered approach to paying the bill is ill-conceived and inefficient. Inefficient because dozens of public and thousands of private plans have become a costly administrative nightmare, with little purchasing power to negotiate the best drug prices.

There is also the issue of fairness. While most people are eligible for at least some coverage for drug costs, far too many Canadians suffer financially trying to pay for medication, or risk their health by not taking prescriptions they need, or not taking them properly to try to save money.

My husband makes too much money barely to qualify for provincial support. The price of everything goes up, support stays the same.

Access to provincial services is a Gordian knot of bureaucracy and interlocked agencies. Provincial pharmacare is a real mess. I have no choice but to cut medications.

This means my heart and thyroid are at risk. I stopped my arthritis meds and no longer have access to cannabis oil for pain.

I know others have it worse. We know that national pharmacare will result in savings. A single purchaser of prescribed medicines, acting on behalf of all Canadians, will have the necessary leverage to negotiate lower prices for the drugs we need.

Billions of dollars of annual savings are expected once pharmacare has been implemented. Families, individuals and employers will save money through pharmacare.

Prescription medicines hold so much promise today. They have become integral to our health care, and vital to improved health outcomes.

Fifty years ago, medicines prescribed in hospital were important enough to warrant inclusion in medicare.

Today, as more and more medicines are administered in the community and at home, it just makes sense that prescribed medicines—wherever they are taken—should be accessible and affordable to Canadians.

In light of the above, it is difficult—if not impossible—to defend treating prescription drugs differently than other health care essentials.

It is not enough to say this is the way it will be, because this is the way it has been. Adding another patch to the current patchwork of public and private drug insurance plans will not address the issue of fairness, access or affordability, nor will it address the need for future sustainability.

It is time for Canada to join other advanced countries and implement a model of pharmacare that will improve health outcomes, manage costs and ensure Canadians can count on getting the medication they need, regardless of where they live, what their income is and whether they happen to have a job with benefits.

We are therefore recommending a national pharmacare plan that approaches prescription drug coverage the same way we approach physician and hospital care—through a universal, single-payer, public system that ensures access based on need, not ability to pay—one in which all residents of Canada can get the medication they need to maintain their physical and mental health.

If we are to recommend that prescription medicines be treated in the same manner as the other essential elements of health care—hospital and physician services—then it follows that the fundamental principles of national pharmacare should be consistent with the principles of medicare, as expressed in the Canada Health Act.

The council proposes the five fundamental principles of medicare, embodied in the Canada Health Act , be applied to national pharmacare:. Any drug plan begins by establishing who is covered, what drugs are covered and how much a patient will pay through deductibles, copayments and premiums.

As things are in Canada, each of these factors varies between public and private coverage and among the different provincial and territorial plans.

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But most of all, they reminded us to heed those uniquely Canadian values: looking out for one another, supporting neighbours and communities through tough times and treating each other with fairness.

They told us if we could harness that intangible thing—what it means to be Canadian—we might just make pharmacare happen.

The result of our national discussion with Canadians is this report. Hopefully, we accomplished what was asked of us.

In the February spring budget, the federal government announced the creation of the Advisory Council on the Implementation of National Pharmacare, and by June , the seven-member council was launched.

Over the past twelve months, we studied Canadian and international models of pharmacare. We travelled to every province and territory and sat down with hundreds of Canadians at meetings, roundtables and town halls.

We had conversations. We heard both heart wrenching and uplifting, inspiring stories. We heard from patients and practitioners, academics and employers, labour and industry, government officials and members of the public.

We commissioned papers. We heard from thousands online and received emails and submissions from thousands more. We listened carefully to the full breadth and diversity of voices and perspectives.

What we heard, particularly from patients, families and advocates, was enlightening, informative and inspiring. What we discovered, however, is that about 7.

Canadian and international research shows that cost barriers can result in people not taking their medicine properly and poor health outcomes.

A recent study looked at what would happen if out of pocket costs were removed from medications for just three diseases—diabetes, cardiovascular disease and chronic respiratory conditions.

We also learned that while about 60 per cent of Canadians are enrolled in private drug plans primarily employer-sponsored benefit plans , these plans cover only 36 per cent of total system-wide spending on prescription drugs.

But we are also seeing an increasing trend of private plans offloading expensive drugs onto public plans, as well as requiring employees to bear a greater share of the cost through annual and lifetime dollar limits to drug coverage.

There are other costs stemming from our patchwork approach to paying for drugs. Having so many public and private plans dilutes bargaining power.

The cost of individual drugs is higher here than in other Organisation for Economic Co-operation and Development OECD countries and we spend more per person per year on prescription drugs than any other OECD country, with the exception of the United States and Switzerland.

The council heard that governments are struggling with soaring drug costs, particularly the high cost of new drugs coming onto the market.

Research by drug companies is resulting in extraordinary treatments—from biologics, made from living cells or organisms, to gene-based therapy.

Challenging to develop and often expensive to administer, they can carry staggering price tags. With our current approaches to drug insurance, whether public or private, these costs are not sustainable.

We must act. The council looked carefully at a range of models in place internationally and in Canada that could serve as a guide for a national pharmacare plan.

We observed that countries with high performing health systems include prescription drug coverage as part of their publicly funded universal health care plans.

We learned that by joining forces, drug plans could increase their bargaining power with pharmaceutical companies, resulting in lower drug prices.

We were told by employers that private drug benefits for their workers were becoming less and less affordable to them.

We recognized the important work provinces and territories have done to provide drug coverage and the need to take this further, in a collaborative way, with federal support.

And we were reminded of those Canadian values of fairness and looking out for and supporting each other. We concluded that the best plan for Canada is to organize prescription drug coverage the way universal health care is set up.

We propose that the government enact national pharmacare through new legislation embodying the five fundamental principles in the Canada Health Act :.

This is a major part of our health care system that affects millions of patients, hundreds of thousands of health care providers and a broad range of dedicated stakeholders.

National pharmacare would start with the creation of a Canadian drug agency preliminary funding for an agency was announced in the federal budget.

The new agency would be an arms-length organization, with strong patient representation, accountable to Canadians both directly and through the federal, provincial and territorial ministers of health.

It would be governed collaboratively by the federal, provincial and territorial governments and would have patient representation on the board.

The agency will be in charge of approving drugs for the formulary, based on both how well they work and whether they offer good value for money.

Because it will take time to choose the right drugs and negotiate prices for them, the initial formulary would be a carefully chosen list of essential medicines covering most major conditions and representing about half of all prescriptions.

This initial list of drugs would be available through national pharmacare beginning January 1, Also by January 1, , a detailed national strategy and distinct pathway for funding and access to expensive drugs for rare diseases would be implemented.

Over the subsequent five years, additional prescription drugs would be added to the national formulary as prices and supply arrangements are negotiated with manufacturers.

Other responsibilities for the agency would include providing guidance on the appropriate use of drugs, and monitoring their safety and effectiveness once they are on the market.

Concentrating all these operations in one organization would make pharmacare more efficient and speed up access to new drugs, as well as improve consistency in access to prescribed drugs across the country.

As with medicare, it will be up to individual provinces and territories to opt in to national pharmacare by agreeing to the national standards and funding parameters of pharmacare.

We recommend the federal government pay for the incremental costs to provinces and territories of expanding coverage and implementing pharmacare in their jurisdictions.

The federal government should proceed immediately with ready provincial and territorial partners, understanding that some jurisdictions may take longer than others to join national pharmacare.

A timeline beginning in and extending to that illustrates the phased approach of pharmacare. There are four arrows representing the different aspects of pharmacare that will evolve over time.

There is strong evidence that user fees create barriers to access, whether in the form of copayments or deductibles.

Research has shown they prevent people from taking their prescription drugs properly, or even at all. User fees are particularly hard on people with complex or chronic health problems and those with low incomes.

Canadians with rare diseases are both anxious and determined to find treatment that might help their condition, and the pharmaceutical industry is responding by developing a growing number of drugs—most of which are extremely expensive.

Over the course of its mandate, the council heard that these drugs can threaten the sustainability of both private and public insurance plans—but at the same time, patients rely on them for life-changing, often life-saving, treatment.

No patient should face costs of this magnitude for any drug. That is why the council is recommending the Canadian government develop a formal national strategy for expensive drugs for rare diseases.

We are also recommending the Canadian drug agency establish a distinct pathway for the consideration of expensive drugs for rare diseases, and a national expert panel to work with patients and their clinicians to determine which rare disease drugs should be funded for which patients.

The national strategy, distinct process and funding for these specialized drugs should be in place in conjunction with the essential medicines list, beginning January 1, Although health care delivery falls under provincial and territorial jurisdiction, the federal government has always played a critical role in developing and safeguarding universal health care—most notably with the introduction of medicare in the s and passage of the Canada Health Act in the s.

The implementation and success of national pharmacare will not be possible without strong federal leadership and funding. The provinces and territories deserve credit for advancing prescription drug coverage in their respective jurisdictions.

It is due to their hard work that we are not starting from scratch. In fact, provinces and territories have built a strong foundation upon which to build national pharmacare.

For that reason, and conscious of divergent federal, provincial and territorial fiscal outlooks, the council is calling on the federal government to pay for the incremental cost of implementing national pharmacare.

The council recognizes the very significant fiscal implications of this investment. But the issue is too important to ignore.

Although national pharmacare requires a substantial investment of public funds, it will result in significant savings to Canadian families and lower the total amount being spent on prescription medications.

We propose that the federal government create a new, dedicated fiscal transfer to support national pharmacare, one that will be long-term, predictable, fair and acceptable to provinces and territories—that takes into account demographics and other variables that impact prescription drug consumption.

Furthermore, we recommend this transfer and other key parameters of pharmacare be reviewed every five to ten years. Any changes to the key elements of pharmacare, including funding, should require approval by the Parliament of Canada and 70 per cent of participating provinces and territories, representing two-thirds of their combined populations.

National pharmacare will save money as lower prices are negotiated for more drugs and as other cost-saving strategies are implemented. The savings for individual Canadians and their families will be significant and tangible.

And with those savings will come the comfort of knowing you and your loved ones will have access to the medicines you need. No more complicated forms.

No more steep deductibles or limits. No more stress. Families and individuals will no longer face the postal code lottery, where access to prescribed drugs depends on which province or territory you reside in.

And Canadians can rest assured knowing that their drug insurance travels with them, right across Canada. Perhaps most importantly, Canadians will have access to medicines based on need, not on their ability to pay.

All Canadians will be treated equally, without exception. That is something to be proud of. And it is consistent with the values that underpin our universal health care system—our values as Canadians.

National pharmacare will mean that employees and businesses no longer have to pay for expensive prescription drug coverage.

No more coinsurance. No more annual or lifetime limits. National pharmacare will provide businesses with much-needed relief from the high and growing cost of prescription drug insurance.

Business owners will no longer have to worry about whether they can afford private drug coverage for their hardworking employees.

They will have the financial room to offer other health benefits to their workers for example, mental health and wellness services, physiotherapy, dental and vision care , to pass on the savings to their employees through higher wages, or to invest in their businesses.

And pharmacare means workers who choose to retire will not, as is the case for many retirees today, experience a reduction in drug benefits.

Part-time and contract workers will, many for the first time, be entitled to prescription drug benefits. National pharmacare will also level the playing field for small, medium and large businesses by ensuring all workers have comprehensive drug benefits, not just those who work for companies that provide drug insurance as a benefit of employment.

For small businesses, many of which cannot afford drug benefits for their employees, pharmacare should make it easier to recruit and retain employees, and maintain a healthy workforce.

National pharmacare means prescribers can finally have confidence their patients will fill their prescriptions.

Doctors and other prescribers will no longer have to ask a patient whether she or he has private insurance, and then modify their prescription accordingly.

Pharmacists will know their clients are being well-served by our health care system. And as more and more prescription drugs are delivered outside hospital, the inequity of drugs being covered by public insurance in hospital but not out will end.

Patients will get the medication they need to get better, to stay healthy, or to manage a chronic condition.

Removing the cost barriers Canadians face when they have prescriptions to fill will make it easier for them to maintain their health or get better, reducing the need for them to visit their doctors or be admitted to hospital.

As previously noted, recent research found that removing out of pocket costs for the medications used to treat just three health problems—diabetes, cardiovascular disease and chronic respiratory conditions—would result in up to , fewer emergency room visits and 90, fewer hospital stays annually.

It will reduce the economic inefficiencies that come with tens of thousands of private plans, which cost three times more to administer than public plans.

It will replace multiple buyers with a single large, powerful purchaser, one that has the clout and authority to negotiate the best, lowest prices for prescription medications for Canadians.

The good news is that these savings can be achieved even as coverage is expanded to cover all Canadians. Our plan also means that Canadians with existing coverage will be better off under national pharmacare.

In other words, adopting national pharmacare will lift every Canadian up, and will allow Canada to address longstanding gaps and inequities in access to prescription drugs while spending significantly less than under the status quo.

The implementation of national pharmacare in Canada is long overdue. Indeed, the same arguments spoken in favour of pharmacare in the s still apply today.

But a lot has also changed since then, making pharmacare even more relevant and more necessary: prescription medicines have a much greater role in improving health and their cost has skyrocketed, putting the whole system at risk of becoming unaffordable.

Our proposal for national pharmacare is transformational and life-changing. It will replace a patchwork of thousands of plans that are becoming less and less sustainable, and still leaving millions of Canadians unable to get the medicine they need.

National pharmacare will be a drug insurance plan that belongs to all Canadians—one that is sustainable, fair and equitable, where Canadians can have access to prescription medicines based on their need, and not their ability to pay.

We know this is a bold and challenging task. But Canadians have told us—by the thousands—that this is what they want.

That this is what we need. And we know we can get it done. Prescription drugs are an essential part of health care. The situation has only gotten worse with the emergence of a growing number of high-cost specialty drugs used to treat chronic, complex conditions such as severe rheumatoid arthritis, multiple sclerosis and cancer.

These new treatments, along with a growing number of ultra-specialized and expensive drugs for rare conditions, are threatening to overwhelm both public and private insurance programs.

In its budget, the federal government announced the creation of the Advisory Council on the Implementation of National Pharmacare the council.

Its task was to advise the government on introducing a national insurance program for prescription drugs—known as pharmacare—which would be affordable for Canadians, their employers and governments.

The government asked the council to undertake a dialogue with Canadians and issued a discussion paper Endnote 1 that outlined a range of possible options on how to move forward with national pharmacare and highlighted the key issues the council should address in its work.

The council started its work without any preconceived preference for a particular model and led a national discussion with Canadians—patients and caregivers, health care providers, provincial and territorial governments, Indigenous peoples, experts and academics, the private sector and other stakeholders—to learn what would work best for Canada.

The council deepened its understanding with research into the fiscal, economic and social aspects of Canadian and international experiences with pharmacare.

To do its work, the council travelled to every province and territory across the country to hear from thousands of Canadians. In each jurisdiction, the council held roundtables attended by patients, their family members, health care providers and academics, as well as representatives from health care organizations, business, labour groups, the pharmaceutical industry, private insurers and employee benefit providers.

Through structured discussions, they shared their perspectives on what pharmacare might look like. In Vancouver, Toronto and Halifax, the council held town hall meetings where any member of the public could attend.

Small group sessions were also organized with Canadians who had limited or no drug coverage to ensure their voices were heard. The council believed strongly that we must look at the issue of drug coverage in Canada through the lens of those with lived experience: patients and their families.

Dedicated engagement sessions were held with patients and with the patient advocacy groups that serve as a voice for Canadians living with a wide range of health conditions.

Some of the stories patients shared with the council are woven through the report. To get input from individuals who could not attend in person, an online platform was open from June to September There were more than 15, responses to an online questionnaire, nearly 1, comments were posted by Canadians, and the council received more than written submissions.

Endnote 2. As they travelled across the country, council members heard first-hand from provincial and territorial officials about challenges and opportunities facing public drug plans.

As well, a national reference group, comprised of officials responsible for drug plan programs and policy in each jurisdiction was formed to share information and insights with the council.

The council also received a briefing from federal officials responsible for the program that provides drug benefits to registered First Nations and recognized Inuit.

As well, the council received briefings from several organizations that play important roles in the drug management system, such as the Canadian Agency for Drugs and Technologies in Health and the Patented Medicine Prices Review Board.

Finally, in an effort to better understand approaches to pharmacare in other countries, the council had discussions with representatives from Australia, New Zealand, the Netherlands and the United States.

A graphic showing the various statistics of council engagement activities over the course of its mandate. The council benefited from a considerable body of work that has been developed over the years on pharmacare and on a range of pharmaceutical issues.

In some areas, we felt that additional work was required to provide the council with the most up-to-date information available, or to delve into specific areas where there are gaps in knowledge.

We commissioned leading experts to provide us with insights on the following issues:. The council also benefited greatly from cost modelling work done for us by Finance Canada.

Our objective was to estimate the costs and savings of national pharmacare as accurately as possible, building on earlier estimates by the Parliamentary Budget Officer.

It begins with an examination of the state of drug coverage in Canada, outlines its challenges and describes necessary improvements.

The report goes on to present what national pharmacare would look like and lays out a detailed plan and timetable, including recommendations to government about how national pharmacare should be implemented.

This includes advice on what components of the plan should be introduced and when, who should be responsible, and how it should be financed.

The report also discusses the key enablers that will need to be put in place for national pharmacare to succeed and concludes with a summary of what national pharmacare will mean for Canadians.

Prescription medicines allow millions of Canadians to prevent and fight disease, manage chronic illness, ease pain, breathe better—in other words, to live healthier and more productive lives.

And yet the way Canada manages and pays for this vital part of 21st century health care is critically flawed. Canada is the only country in the world with universal health care that does not provide universal coverage for prescription drugs.

Our fragmented landscape of drug benefit plans leaves too many Canadians unable to afford the drugs they need. Drug costs have been steadily climbing around the world.

Endnote 3 The cost of individual drugs is higher here than in other Organisation for Economic Co-operation and Development OECD countries and we spend more per person per year on prescription drugs than almost any other OECD country, with the exception of the United States and Switzerland.

Endnote 4. There are more than government-run drug insurance programs in Canada—often designed to provide drug coverage for vulnerable groups including seniors and people on social assistance.

There are also over , private drug benefit plans, usually offered as employment benefits but also for sale directly to individuals.

Nevertheless, high percentages of Canadians consistently report in surveys that they have either not been able to pay for at least one prescription, or have not taken their medicine as instructed because of its cost.

This situation, in a wealthy country with a commitment to social equity and an established universal health care system, makes no sense and led to the announcement of the Advisory Council on the Implementation of National Pharmacare in February During the year of its mandate, the council has done a financial, economic and social assessment of Canadian and international models of pharmacare and consulted across the country—with patients, health experts and health care providers, the private sector, labour, academics, provincial and territorial governments and Indigenous peoples.

The idea of pharmacare—a publicly funded, universal prescription medicine insurance plan—is not new in Canada.

As the box shows, the studies did not all recommend the same model for pharmacare but they all concluded some form of it would result in better health for Canadians and lower costs for families, employers and governments.

If you think being an electrician keeps you busy, try being one who has to watch his diet, exertion level, hydration and sugar levels, all at the same time as wiring a building—safely.

There are often long hours, long days and long weeks. Not ideal conditions for a diabetic. I could see their point, but it was a hard pill to swallow pun intended.

Is it ideal? No way! Look, I work hard, I do my bit. Supreme Court Justice Emmett Hall was appointed to lead the commission in and his final report laid the groundwork for universal, public health insurance introduced through the Medical Care Act in The commission also called for the creation of a national agency to negotiate prices, decide what drugs should be covered, monitor prescribing and drug safety and provide objective information about medicine to patients and health care providers.

Chaired by Senator Michael Kirby, the committee looked at the federal role in health care, focused mainly on supply, human resources and the need for greater competition.

On issues related to prescription drug coverage, it said that no Canadian should suffer undue financial hardship because of the cost of prescription drugs.

The committee recommended introducing catastrophic coverage and said the federal government should cover 90 per cent of the cost of the program.

It also called for the federal government to work closely with the provinces and territories to establish a single national formulary.

The House of Commons Standing Committee on Health heard from expert witnesses on pharmacare and commissioned a study by the Office of the Parliamentary Budget Officer to examine its potential for cost savings.

To ensure all Canadians have affordable access to prescription drugs, the committee recommended establishing a universal, single-payer, public national pharmacare program by expanding the Canada Health Act to include prescription drugs dispensed outside of hospitals as an insured service.

Each of these studies also said that national pharmacare should be consistent with the principles and values of the public medicare system, regardless of the specific model each study recommended.

With that consensus, with the obvious need and the strong support from Canadians, why do we not have a system of national pharmacare?

The answer to that goes back to the very beginning of universal, publicly funded health insurance commonly called medicare in Canada. The idea of universal, public coverage for health care started gaining popularity in Canada after the Great Depression hit in , when progressive organizations and political parties began promoting the idea.

Endnote 6 In , Saskatchewan was the first province to introduce universal public hospital insurance including coverage for drugs administered in hospitals , with British Columbia and Alberta following a few years later.

In , the federal government passed the Hospital Insurance and Diagnostic Services Act , which offered to share provincial and territorial costs for hospital and diagnostic services, provided that provincial governments met certain conditions.

Within four years, all provinces and territories were providing residents with access to hospital services at no charge. In , Saskatchewan again led the country by expanding public coverage to include physician services.

The move was fiercely resisted by opposition politicians and doctors who went on strike , foreshadowing the reactions of doctors and some politicians in every province in the years to come as medicare was gradually introduced and expanded.

Endnote 7 Despite that powerful opposition, public support for medicare remained strong. We believe that the only practical and effective way of doing this is through a universal, prepaid, government-sponsored scheme.

The establishment of public insurance for hospital and physician services across the country irrevocably cemented the foundational concepts of Canadian health care—universal access, public administration and zero cost at the point of care.

In , the Canada Health Act further codified these ideas in its five principles—that health care should be publicly administered, accessible to all, comprehensive, universal and portable.

Neither the Medical Care Act nor the Canada Health Act , however, included coverage of medicines prescribed outside of hospitals. When medicare was introduced in the s, prescription medicines played an important but much more limited role in health care, with a range of fairly inexpensive drugs used to treat common conditions.

Government officials decided to focus on the most important and expensive components of health care at the time—hospitals and physician services. Although prescription medicines were intended to be added at a later date, changing economic conditions, shifting priorities, and the ups and downs of federal-provincial-territorial relations sidetracked efforts to bring about national pharmacare.

In the absence of pharmacare, provinces and territories developed their own drug plans. Most were designed for vulnerable groups, such as people on social assistance and seniors.

At the same time, employers began offering health benefits including prescription drugs, vision and dental care , as a way to attract and retain talent in a competitive labour market.

The more than drug plans run by federal, provincial and territorial governments are aimed at improving access to prescription medicines primarily for people who might otherwise not be able to afford them.

Each plan is different, but often tailored for specific groups such as seniors, children, those with low incomes, or people with serious medical conditions.

The federal government provides drug coverage to registered First Nations Footnote i and recognized Inuit populations, federal inmates, members of the Canadian forces, veterans, resettled refugees and refugee claimants.

In addition to those public plans, all provinces have a form of safety net coverage for their residents. The most common form, often called catastrophic coverage, protects people from the financial catastrophes very high prescription drug costs can trigger.

British Columbia, Saskatchewan, Manitoba, Ontario, Nova Scotia, Prince Edward Island and Newfoundland and Labrador offer catastrophic coverage, which people become eligible for when their total drug costs exceed a certain percentage of household income their deductible.

Some provinces have more generous deductibles than others. Safety net programs in other provinces are based on premiums.

In Alberta and New Brunswick any resident has the option of enrolling in public drug coverage by paying a premium.

Quebec is the only Canadian jurisdiction that has achieved universal drug coverage and it did so by making drug insurance mandatory for all residents.

Residents who are not eligible for private insurance through their employer or occupation are required to enrol in, and pay premiums for, the provincial drug plan some vulnerable groups, such as low-income seniors, are exempted from paying premiums.

While the territories do not offer broad-based safety net programs, many residents are covered under the federal Non-Insured Health Benefits Program, which provides drug coverage to over , registered First Nations and recognized Inuit across Canada.

The lack of universal public drug coverage in Canada has created a market for private drug coverage. Private drug plans are generally intended to attract workers and support workplace productivity, not serve as social safety nets.

Most private plans have open formularies—that is, the lists of drugs they will pay for includes almost every medication Health Canada approves for use, regardless of whether they are more or less effective, or cost more or less, than other available drugs.

This gives physicians and patients access to the broadest possible range of treatments, but also can lead towasteful spending because there is little incentive for patients or providers to choose a lower cost, equally effective therapy.

For their part, public formularies emphasize effectiveness and value for money. Source: Law, M. Available from Health Canada by request.

Source: Law, M Source: Law, Michael. Linking drug coverage to employment presents another potential problem—it could limit job choices for people.

Notably, governments are some of the biggest sponsors of private drug insurance plans. Most public sector workers at the federal, provincial, territorial and municipal levels—including those working in health, education, and social services—have prescription drug coverage as a benefit of employment.

This means that as many as 30 per cent of all private plan beneficiaries are public sector employees whose benefits are delivered by private health insurers but paid from general tax revenues.

However, as concerned as governments are about runaway prescription drug costs, these plans are more expensive and inefficient than public drug plans.

I take common, but costly, medications for asthma and ADHD. Now I use our public provincial pharmacare program to cover the majority of my medications as it is still affordable.

At the end of each year, I calculate how to deal with health costs for the next year: is it cheaper for me to pay the provincial deductible and medical expenses out of pocket, or should I get a private medical plan?

With luck and continued work my income will increase, but so will my deductible, to the point where I will be paying the full cost out of pocket.

In our unstable job market, why do we continue to tether drug insurance to stable employment? Where does that leave the creatives and entrepreneurs who just happen to have a chronic illness?

How we treat disease is evolving rapidly as pharmaceutical companies push their science further and further in search of new treatments and cures.

The landscape of drugs available on the Canadian market is crowded and complex, and pharmaceutical companies continue to introduce new and specialized products at a rapid rate.

Not all drugs live up to initial expectations and others become outdated quickly as new treatments for the same condition are developed.

Newly launched drugs can generate excitement, but some offer little benefit over older, lower cost alternatives.

Annual Report It is not just research and development that makes these new specialty drugs so expensive. Many new medications are not just another pill to be dispensed at the pharmacy and taken at home.

Often, they are given to patients by injection or infusion and require special storage and handling, and the patients who take them need close monitoring throughout their treatment, all of which adds costs.

Many of these new drugs are biologics, which are made from living cells or organisms using biotechnology many new cancer drugs are biologics, as well as drugs used to treat rheumatoid arthritis, irritable bowel disease and psoriasis, among others.

They are harder to develop and manufacture than traditional chemical drugs. As well, pharmaceutical companies are developing a growing number of drugs for rare diseases.

These products are often the only treatment available for conditions that may be seriously debilitating or life-threatening, but the cost of development, small numbers of patients and few treatment options combine to drive up costs.

At the same time, some new and expensive specialty drugs are for relatively common conditions, such as migraines, where demand and therefore spending could be high.

These new drugs can be life-changing for patients, but they are often staggeringly expensive. Today, top-selling brand name drugs often cost thousands or tens of thousands of dollars per year.

Endnote 9 It does not take long, in the face of such overwhelming costs, to realize we can no longer continue with a fragmented, expensive, out-dated and poorly thought-out approach to funding such a vital element of health care.

A system that depends on every player assuming someone else will find money somehow instead of planning and organizing to ensure needs are met cannot serve the needs of Canadians in the future, or even in the short run.

While it was a relief to finally know what was wrong, our world took a very sudden, complex and traumatic turn. He takes 25 medications daily to deal with symptoms.

And when you add up the copayments on 25 medications…sigh. Myself, my son and my other children moved to the city to be closer to appointments and clinics, while my husband had to stay for his job.

I had to quit mine as it was impossible to juggle it with all of the appointments and my family. My faith has been my touchstone throughout this, and I am thankful for it, my family and friends.

I know if you were in my position, I would not hesitate. In the absence of national pharmacare, a patchwork of public and private drug plans has evolved in Canada.

This fragmented system is not equipped to handle the increasingly complex and expensive medications surging onto the market and is failing Canadians in a number of fundamental ways.

The most profoundly unfair result of not having national pharmacare is that while the majority of Canadians have at least some insurance for prescription medication, many people have none at all.

Endnote 11 This likely reflects both the uninsured people who have no coverage and the underinsured who have inadequate coverage. Some of the difference in numbers may be due to catastrophic coverage.

In that situation, coverage may be more theoretical than real. One study found that 4. Endnote 12 So while only a small proportion of Canadians are actually completely uninsured, a much greater number are underinsured—the two together probably make up 20 per cent of the population—leaving 1 in 5 Canadians struggling to pay for their prescription medications each year.

A substantial proportion of underinsured Canadians have some form of private insurance. But premiums, deductibles, copayments, coinsurance and annual and lifetime limits mean that out of pocket costs can still be high.

Endnote In this hypothetical example, we present Nadia, a year-old single mother with two children. She and her family have prescriptions for gastric reflux, anxiety, birth control, asthma, attention deficit hyperactivity disorder and the occasional ear infection.

With public drug coverage, Nadia would have to pay different amounts, depending on where she lived in Canada. For those Canadians eligible for government public drug benefits, there are differences in coverage within and across provinces.

Federal, provincial and territorial drug insurance plans have broadly similar goals—generally, protecting the health of vulnerable people—and a review by the Patented Medicine Prices Review Board found that for the majority of drug classes, the public drug programs all provided access to equivalent though not identical drugs.

Endnote 14 But differences in who is covered, how drugs are funded, the amount of out of pocket costs and the rules to be followed are all contrary to the idea that all Canadians should have equal access to health care—based on need, not their ability to pay or where they live.

One province may require doctors to get authorization from the plan before prescribing very expensive drugs or for drugs with a high potential for misuse, while other provinces have no such barriers.

He was recently diagnosed with advanced lung cancer. One of the most common arguments against pharmacare is that most Canadians have private drug insurance.

Also, prescription drug coverage is not evenly distributed among working people—according to the Wellesley Institute, 73 per cent of full-time employees report having medical benefit coverage while only 27 per cent of part-time employees do.

Endnote 17 Accessing private drug coverage can also be a challenge for the many Canadians who are self-employed or work temporary jobs, such as contract or casual employment.

Endnote 18 That means women, people with low incomes and young people—who are all more likely to work in part-time or contract positions—are often left without drug coverage, simply because of the type of work they do.

The nature of work has changed rapidly over the past two decades. Changing business practices and the emerging gig economy—where more people are working temporary contracts or are self-employed—are reducing opportunities for stable, full-time work.

As a consequence, a growing number of Canadians are finding themselves without access to workplace drug benefits. Implementing national pharmacare would help ensure that all Canadians, regardless of what kind of job they have, enjoy fair access to prescription drug coverage now and into the future.

In a national survey, 23 per cent of Canadians told Angus Reid they or someone in their household had not taken their medicines as prescribed in the last year because they were too expensive.

Endnote 21 A recent study found almost 1 million Canadians had cut spending on food and heat to pay for medication, Endnote 22 while another found 2.

Endnote 23 Cost-related non-adherence not taking a prescription properly because of its cost is two to five times higher in Canada than in comparable countries with universal pharmacare.

Of those who told the Canadian Community Health Survey they could not afford one or more of their prescriptions, about 38 per cent had private insurance coverage and 21 per cent had public coverage.

Endnote 26 Canadian and international research shows that kind of direct charge makes people less likely to take prescribed drugs.

Endnote 27 And the costs that people with private plans pay—between copays and deductibles—is increasing, from 10 per cent of their drug costs in to 15 per cent in Endnote 28 As well, the overall share of private health insurance premiums paid by employees has risen rapidly from 26 per cent in to 40 per cent in Source: Statistics Canada.

Canadian Survey of Household Spending, Table Another cost patients face is caused by some private and public plans not starting coverage until patients have paid a certain amount of their drug costs themselves, which is called a deductible.

Several studies of the impact of out of pocket charges on Canadian seniors and people on social assistance found that more of them were admitted to hospitals and nursing homes after copayments were introduced; death rates increased as well.

Endnote 33 , Endnote 34 A study found approximately one-quarter of Canadians who said drug costs were an issue for them visited a physician, emergency room or hospital more than they would have otherwise.

Endnote 35 Researchers recently looked at the impact that removing out of pocket costs for medications would have on just three diseases—diabetes, cardiovascular disease and chronic respiratory conditions.

Endnote 37 Severe health problems caused by missed medication may eventually force people to stop working altogether.

Diabetes management has always been a team effort between my Mom and me. My diabetes has always been hard on my family and I felt guilty growing up.

I know better, but I often reuse my syringes, skip tests or hold off on an injection a little longer to make my insulin last. To add insult to injury, I just found out that I have inherited sleep apnea.

With needles, test strips and insulin, it still really adds up. My condition will never go away. With the economy the way it is, I feel the likelihood of me finding a good job with benefits is pretty low.

With a pre-existing condition that will deny me private coverage, how will I cope? There have been steep increases in spending on prescription drugs used outside hospital in recent years.

However, an increasing number of the drugs developed for use outside hospital are expensive specialty drugs that are steadily driving up the price of treatment.

Since , the average annual cost of specialty drugs has increased nearly 13 per cent per year. Endnote 38 The average cost of all drugs has increased by 7.

High-cost specialty drugs are not the only reason spending has increased: growing rates of chronic disease—such as diabetes and chronic obstructive pulmonary disease COPD —have contributed too.

Endnote 41 Furthermore, those costs are projected to grow by about 6. Some employers try to manage rising drug costs by trimming wages and other employee benefits, or by encouraging employees to shop at less expensive pharmacies.

An increasingly prevalent way to contain costs is to cap the amount of prescription drug benefits a plan member and their family can receive, either annually or over a lifetime.

From to , the number of private plan members with an annual or lifetime maximum on their drug coverage grew by around 40 per cent so that today more than a quarter of private plan members have capped coverage.

Endnote 42 Employees who reach their plan maximum pay for additional costs out of their own pocket or may move on to a public drug program if they are eligible.

This trend to capping benefits is expected to accelerate as drug costs continue to climb. Pierre and Laila are a working couple in their forties.

Pierre drives for a local moving company and Laila works at a community centre. Laila is taking several prescription drugs for ulcerative colitis, one of which is a high-cost biologic drug.

Prognosis and survival are determined by sorting through a slew of predictive factors; how you respond to treatment is as varied as there are patients.

Luckily there are some very good treatment options available. They are life-changing, but staggeringly expensive.

The carrier decided to boost the premiums for the coming year. He was displeased. Unaware that I was the patient, the president grumbled to my spouse about ferreting out who this person was, not knowing he was speaking to the very partner.

Thankfully, my husband is working again, but we worry that it may happen again. Senior management at this company does display empathy to employees and their families.

We hope the sentiment lasts! How is it in a country like Canada that employers seem to have the unfettered right to fire someone due to an illness in the family?

There are other reasons private drug plans are looking less sustainable. Unlike public plans, which tend to fund only proven, cost-effective drugs, private plans have traditionally paid for nearly every drug approved by Health Canada, regardless of effectiveness or the value for money it offers.

Private plans are concerned that expensive new drugs, including biologics and drugs for cancer, will drive costs to levels companies will not be able to afford.

Endnote 43 To counter the impact of rising drug costs, some private insurers are starting to limit the selection of drugs they will pay for, or raising premiums.

According to the Canadian Life and Health Insurance Association, premiums for extended health benefits grew at an annual rate of 3. Provincial and territorial governments are also struggling to cope with rising drug costs.

These cost pressures have the potential to undermine the ability of provincial and territorial governments to provide services within and beyond health care, such as education and infrastructure.

In a recent report, the Parliamentary Budget Officer found health care costs may threaten provincial and territorial government finances over the long term.

Endnote 45 Rising drug costs are forcing provinces and territories to make difficult decisions about who is eligible for their programs and which drugs they will cover.

Source: Canadian Institute for Health Information. All countries struggle with the rising cost of drugs, but in Canada paid the third highest prices for brand name drugs and the seventh highest prices for generic drugs among the 34 countries of the OECD.

There are a number of reasons we pay more than other countries; one of the most important is buying power. In Canada, having thousands of different public and private insurance plans dilutes our negotiating power with global pharmaceutical firms.

In an effort to counteract that, the provinces and territories established the pan-Canadian Pharmaceutical Alliance pCPA in to negotiate jointly on drug pricing and supply arrangements such as maximum expenditure agreements on behalf of participating public drug plans the federal government joined in Other OECD countries also operate more efficiently when it comes to approving new drugs and managing coverage for them.

Many have single national agencies or several closely-related organizations to manage medication approval and coverage. In Canada, however, the process that takes a drug from the research lab to the medicine chest is complex, decentralized, costly and slow, as shown in Figure Another factor that reduces the value Canadians get for the money they spend on prescriptions is the inefficiency of a mixed system.

Administration costs are generally three times higher in the private sector than the public sector, and that gap has widened over time. In , administration accounted for 2.

Since then, the public sector share gradually declined to 1. Endnote 47 Between these higher administrative costs and the amount kept as profits, private insurance adds considerable costs to an already expensive sector.

The fractured approach to prescription drug coverage drives up costs in another way: it gets in the way of gathering data needed to deliver good care and plan for an efficient health system.

The evidence is clear. Our current approach to funding and delivering prescription drugs is failing Canadians.

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