Front Burner - Could pharmacare in Canada be a reality?

Episode Date: March 21, 2019

This week's federal budget laid some initial groundwork for the possibility of a national pharmacare plan in Canada. But with a contentious election year ahead, there are still plenty of questions around how a strategy could be implemented. Today on Front Burner, Globe and Mail health reporter Kelly Grant explains how the pharmacare debate is unfolding and what we can expect from the Liberals in the coming year.

Hey there, I'm David Common. If you're like me, there are things you love about living in the GTA and things that drive you absolutely crazy. Every day on This Is Toronto, we connect you to what matters most about life in the GTA, the news you gotta know, and the conversations your friends will be talking about. Whether you listen on a run through your neighbourhood, or while sitting in the parking lot that is the 401, check out This Is Toronto, wherever you get your podcasts. This is a CBC Podcast. CPA 21, how do you read?

I really want to know what happened, and it makes me extraordinarily angry that it's always been a big secret. Uncover Bomb on Board. Investigating the biggest unsolved mass murder in Canada. CP Flight 21. Get the Uncover podcast for free on Apple Podcasts and Google Podcasts. Available now. Hello, I'm Jamie Poisson. So this week, the Liberal government unveiled a new federal budget. And with an election coming up and the SNC-Lavalin scandal still looming over the party, the budget had a lot of items meant to entice voters, including money for a Canadian drug agency.

Which could use its bulk buying power to negotiate better prescription drug prices on behalf of all Canadians. And it's got a lot of people wondering if national pharmacare is closer to being on the table. Kelly Grant is a health reporter at The Globe and Mail who's been covering this story. She's here with me now to explain what a national pharmacare plan would mean and how much it could cost. But first, what it's like to live without the drugs you need. I'm speaking to an Albertan senior named Winnie Pearson. That's coming up on FrontBurner. along with 29 years ago I had a massive coronary heart attack and so I'm on meds for my heart and over the years was pretty good until about 10 years ago and the knees decided to go and I've just been diagnosed with rheumatoid arthritis. I'm sorry to hear that Whitney.

How does that affect your life? It affects it greatly because my income, my total annual income, maybe this year I may hit 20 a year. So I'm on basic pension. And what kind of choices do you have to make to be able to take those drugs? Buy less food, can't afford to eat like salads and fruits and all those vegetables that are out there. I can't afford them. It's a, every three months I go into a bit of a frenzy because, okay, I really got a budget. I really got to take care. Fortunately, I get my GST quarterly.

And so that helps five days later after, five or six days after I get my drugs filled. So that helps. I imagine this, these issues that you're having with money also cause anxiety for you, which exacerbates your health issues. Yeah. Yeah. And I mean, I try to keep a happy, happy life. But when you live alone, you do the best you can. And yeah, there's some days where you can get really down and depressed thinking of, oh boy, how am I going to do this? Where am I going to get that?

I can't have this. And so, Winnie, would a national pharmacare program, that would benefit you? Olé, Jimmy. Absolutely, Jamie. Absolutely. That would be the best medicine if they can put it out there. Winnie, it's been a real pleasure talking to you today. Okay, so that's Winnie. And I suppose for the purposes of this podcast, you can all just call me Jimmy now. Now on to Kelly to talk about what's happening nationally and to parse out the debate around all of this. Kelly, thanks for joining us today. Thanks for having me.

Kelly, thanks for joining us today. Thanks for having me. So the beginnings of a national pharmacare plan were sort of dangled, if that's the right word, in front of us during the federal budget. We believe strongly, as does our government, that no Canadian should have to go without the medication they need simply because they can't afford it. Can we go over what was actually promised here? Okay, so I would say that this is sort of a timid but important step towards pharmacare. So they promised sort of two biggish things. One is $35 million over four years to set up a transition office for something called the Canadian Drug Agency. Okay, I love those transition offices. Yeah, but this I swear

they're gonna need a transition office because this is complicated. But basically, the main thing that this new office would do is create something called a national formulary. So that would be a list of drugs covered for everyone, regardless of ability to pay. And that's something Canada doesn't have right now. We have all these different public and private drug plans that cover a slightly different list of drugs. So that would be sort of the main new thing that the agency does. And then it would take on two kind of existing things that the system already does. One of them is negotiate drug prices with drug companies,

which is something we do in sort of an ad hoc fashion through an agreement between the provinces. And the other thing they would take on is something that is known as a health technology assessment. Okay. So this is where, right now we have two organizations that do this in Canada, one for Quebec and one for the rest of Canada. And what they do is when a new drug is approved, they actually look at the science and they say, what's the evidence? Does this drug actually work? Is it any better than what's already on the market?

And what's the value for money proposition? Basically, provinces, should you pay for this or not? So the idea would be to bring all those functions under this Canadian drug agency. The other thing they promised is a little bit down the road, but they promised a billion dollars over two years beginning in 2022. So basically, if you reelect the Liberals. We could have a whole new government by then. Yes, exactly.

But just for the sake of argument here. Yes, let's assume that the SNC-Lavalin scandal does not continue to dog Justin Trudeau. And then he becomes a prime minister in October. So what happens? So then this is on the really thorny issue of rare disease drugs. And what they've said is that they're going to come up with a national strategy for these really expensive drugs for rare diseases and then commit a billion dollars over two years and possibly another 500 million each year thereafter to help actually pay for the cost of these drugs. It's not just dollars and cents to these moms and dads. It's nights spent sleeping by a hospital bed. It's a constant worry that never goes away.

It's a constant worry that never goes away. And it's knowing how much happier and healthier their kids could be if they could just get the treatment that they need. So essentially we've got two main promises in the budget. The first is the creation of the National Drug Agency, arguably the most significant thing that's being promised in the budget. They're going to create a list of drugs that they think should be available to all Canadians, whether they can afford them or not. They're also going to do research

and evaluate the drugs that they think should be available to all Canadians. And then we've also got money earmarked for drugs for people with rare diseases. Yeah, that's right. So we know that these measures, they alone will not fully close the gap for people who need prescription drugs

and can't afford them. But they do mark important first steps on the way to a system that helps all Canadians to get the medicine that they need. And there's another reason why we're talking about national pharmacare, right? Yeah, and that is that actually a year ago during the last budget, Finance Minister Bill Morneau announced the creation of an advisory council on the implementation of pharmacare. His team will have a mandate to study, evaluate, and ultimately recommend options on a path forward. And so this group, which is led by Eric Hoskins, who's a former health minister in Ontario,

has been traveling across the country, doing consultations, talking to people, talking to stakeholders. Our many months of public engagement have been, quite frankly, eye-opening and very informative. And they released an interim report in March, just before the budget, that included among its recommendations the creation of this drug agency that the budget mentioned. And they are also preparing to do a final report, which is supposed to come out before the end of June, and will lay out what their specific recommendations are for how pharmacare should work and what the model should be. And people are waiting to see what that report says, right?

Yes, people are definitely enthusiastically waiting to see. I don't remember ever hearing from an individual over the last almost year now who said that the current system is adequate. Everybody believed that we needed national pharmacare. They might have differed in terms of what they imagined that to be, but the goal is really identical for everyone. And so what would national pharmacare actually look like? So that is an excellent question. And it is like sort of the main question that we're all waiting to see what this National Advisory Council does.

So are they going to recommend a single payer system where drugs would be treated the same as hospital services and doctors? Only the government can pay. And the government can pay for them. It's free and the government pays, right? can pay. And the government can pay for them. It's free and the government pays, right? Or do they recommend something that's more modest that keeps the existing system where you either pay in a pocket, get your drugs through a public drug plan, or you've got a workplace insurance plan? They could recommend that that basic system stays in place and then they fill the gaps so that what they do, rather than totally upending the system, they try to figure out a way to take people who can't currently afford their drugs

and find a way to help them get the drugs they need. And how would they fill those gaps? So that is like another excellent question we're totally waiting to see. You're just flattering me today during this conversation about pharmacare. Well, you know, I have lots of questions about this too, right? And we just don't have answers about what they're going to recommend. But, I mean, one of the things they could do theoretically is they could take a look at some of the provinces that have more robust coverage, right? And they could just sort of make the public plans stronger, right?

Because provinces do have programs that help you pay for their drugs. Yeah. I mean, basically the way to think about how the government plans generally work is that if you're on social assistance, if you're a senior, or if you have catastrophic drug costs, like, you know, the kind of thing that would bankrupt you, there are government programs that will pay for some or all of your costs. But often what they'll do is they will leave you having to pay a high deductible or a copay. And for some people, that's really hard to afford, right? So you could take those existing programs and try to close those gaps. You could erase the deductibles. You could erase the co-pays. You could introduce insurance for people who aren't

quite poor enough to qualify for social assistance, but aren't well off enough or employed by a place that offers a good workplace program. So that's what is really meant by the idea of filling the gaps. Are there other countries where either of these models are working well right now? So there are lots of countries, especially in Europe, where they have a public health care system and their drugs are mainly covered through a single payer government system. And a lot of those seem to be working fairly well. In Sweden, the doctor writes a prescription. The pharmacist checks to see if it's on a list of approved medications.

If your prescription is on the list, it's covered. You pay a small user fee called a co-pay. If your doctor prescribes a more expensive brand name drug not on the list, the pharmacist automatically substitutes a cheaper one that's listed. Now, there are often still a place and a role for private insurance and drugs that tend not to be covered by the system. But really, Canada is a bit of an outlier in that we have this universal health care system that doesn't have a promise of prescription drug coverage. You mentioned before that, you know, even with the help that provinces give, there are Canadians that are still struggling to pay for their drugs.

And do we know how big of a problem this is? So what the National Advisory Council said is that about one in five Canadians are either uninsured or underinsured. So the uninsured would be people who just flat out have no health insurance. And that usually tends to be people who are working low wage jobs where they don't qualify for social assistance, but their workplaces don't provide any kind of benefits. So those people have nothing. And then there are people who are underinsured. And so those would be the kind of people who have some, say, workplace insurance, for example, but there's a high deductible and they can't afford the deductible. Okay. So one in five people are either underinsured or uninsured entirely. And we have like 37 million people in this country.

Then we're talking about 7.5 million people who are directly affected by this. Roughly, yes. So if it's working so well in other places and we're an outlier, then why don't we just have this? Because it's more complicated and expensive than it sounds. So generally the big pitch for pharmacare is, hey, if we do this, we can bring our overall spending on drugs down and we can cover more people. So why don't we do it? Right. And I just want to unpack that a bit. The reason that we could bring our entire spending on drugs down is why? So it's a couple of different reasons. One, there's some thinking that if we had a more systematic way of negotiating across not just the public plans, which already

do some joint negotiating, but also the private plans that in general, we could use that full buying power to drive down drug prices in our negotiations with drug makers. We could also make smarter choices about what we cover and what we don't cover to save money. So that's really where something like the national formulary would come in. There are a lot of drugs that come onto the system that are not really any better than what already exists and sometimes cost a whole lot more money, right? And a lot of those drugs are covered by private plans. So in a world where you could say, you know what, we're only going to cover a certain number of drugs that have the best evidence and the best price. If you got the price down, you changed

the usage pattern, you were more aggressive about making sure people switch to generics and biosimilars, you could bring the whole tab down. But that requires a level of coordination that we don't have in a world right now where we have more than 100,000 different private insurance plans and more than 100 different public plans. So I imagine the pushback to that is on two fronts. The first is the idea that we could bring the cost of drugs down by negotiating as a single actor. Wouldn't the argument against it be that it's still then the government that has to take those costs? And so this is just going to end up costing taxpayers a lot of money and, you know, we're running a deficit. Well, both of those things are true. Like you could, even Pharmacare's boosters, like say that they believe that you could

bring the overall bill down, but like absolutely everybody acknowledges that the governments will have to pay more. So in 2017, the parliamentary budget officer was asked to crunch the numbers here. And what the office came back with was an estimate that the overall savings to all payers would be somewhere in the neighborhood of $4.2 billion if you did everything right. But you would be taking a tab that right now is split across patients, private insurance, and the public system, and you'd be putting it all onto the public system. And so the governments together as a whole, the office estimated it would be another $7.3 billion for the public

system to take this up. So essentially what you're saying is that the overall cost of what Canadians spend on drugs would go down. But because the government is taking all the costs, the government's portion of what they're spending on drugs would go up. That's exactly right. Which is the controversial concept when we're talking about budgets. It is really the best way to sum up why we don't have pharmacare. Right. Because you have to get the federal government, 10 provinces to all agree to do the same thing and then spend a lot more money.

Right. And I think we can see that playing out right now with carbon taxes, for example. Saskatchewan and Ottawa faced off in court over the federal government's carbon pricing plan. The case involved five judges, more than three dozen lawyers and 16 interveners. It is not going fantastically well. Well, and I think that, you know, even when the Liberals launched this advisory council last year, they were facing a really different political landscape in the provinces, right? You've got new governments in Ontario and Quebec, both of whom I think are much less friendly to the idea of a national pharmacare program than their predecessors would have been. I mean, you never know how things will go, right? If the federal government is willing to put a lot of money on the table and things could happen. I'm not saying it's

impossible. I just think it's a tougher political table for the liberals than it was a year ago. And the other pushback that I would imagine you would hear is, I'll pick up on what you said earlier, this idea that the government will negotiate for certain drugs, and then that's the drug that will be available to you for this particular ailment. I would imagine that some people won't like being told what specific drug they have to use to address their medical issue. I think that's another thing that'll be very complicated here. Although people won't technically be told, they'll be told, here's what we fund. And if you would like something else, you'll have to figure it out on your own. So, I mean, that could be a very good thing in the sense that

having like a very evidence-backed list of drugs that are good value will probably be a good thing for everybody on the whole. But to give you like an example of drugs that are good value will probably be a good thing for everybody on the whole. But to give you like an example of something that I think sometimes people don't think about in this pharmacare debate is right now there are a lot of drugs that private insurance covers that say the provinces don't. I can think of like one perfect example of a very expensive cystic fibrosis drug called Orkambi, which costs about $250,000 a year. And the HTA organization that I discussed before looked at this drug and said, we don't think the evidence here is good enough to justify spending this money. And so no provinces cover it, right? But it's approved by Health

Canada because all Health Canada has to do is say that the benefits outweigh the risks. They don't have to sort of consider larger questions of value. So because it's approved here, there are people who are on this drug through their workplace insurance plan. And if you then went to a single payer system and that system followed the advice of the health technology assessment folks, you'd have a bunch of people who have a serious disease who are getting a drug that they think is working for them, lose access to that drug. Right. I can imagine they would not be happy about that. Well, I just don't think there are people who are thinking about the idea of the arrival of national pharmacare, meaning some people who previously got drugs would now not get those drugs covered. And maybe they shouldn't be getting those drugs

covered because perhaps the evidence isn't good enough for them or the value proposition isn't good enough. But it doesn't mean people aren't going to be upset about that. Right. You know, we talked about the scope of people who are uninsured or underinsured. There are also, you know, huge swaths of people that have insurance for their workplace. And so why should these people care about a national pharmacare program, especially if it means spending more government money? Well, I think for a couple of reasons. I think one of them is that these private insurance plans are under a lot of fiscal pressure, especially because of the arrival of so many new high-priced drugs. And that means people pay more in premiums. It also means that, let's say, for example, you're a person who does have one of these diseases where you're getting an expensive

drug. It's covered through your workplace insurance plan. I mean, if you're looking to switch a job, right, like that becomes a barrier to you moving from job to job, right? It could be like a real ball and chain for your mobility. Totally, right? And that's not, I mean, you want people to have the flexibility, the same way that you don't feel as though, you know, if you have cancer or need a hip, that you need to be attached to a specific workplace to get your insurance. So I think those people should care in terms of their premiums and in terms of not being sort of attached to their jobs in that way. And, you know, then there's just the caring about all of your fellow Canadians who don't have access to that kind of coverage. We just spoke with Winnie Pearson, who's in her late 70s, and she's essentially having to make decisions right now over fresh fruits and vegetables or the drugs that she needs for her chronic pain issues. And part of this discussion is what kind of society do we want to live in. Kelly, thank you so much. I know that this debate can be really wonky sometimes.

And so I really appreciate you coming here and sort of talking to us about it in a really accessible way. Thank you. I'm wonky, so thanks for listening to FrontBurner. For more CBC Podcasts, go to cbc.ca slash podcasts. It's 2011, and the Arab Spring is raging. A lesbian activist in Syria starts a blog. She names it Gay Girl in Damascus. Am I crazy?

Maybe. As her profile grows, so does the danger. The object of the email was, please read this while sitting down. It's like a genie came out of the bottle and you can't put it back. Gay Girl Gone. Available now.