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Is Ontario’s youth pharmacare proposal just a symbolic gesture?

A pharmacare plan for youth instead of the most needy is a missed opportunity, say some drug policy experts

Roger Collier | CMAJ | May 4, 2017

The initial response from pharmacare advocates to the Ontario government’s plan to cover all medications for people under age 25 was generally positive. But some drug policy experts, after reflecting on the details, say they are actually less than impressed.  Everyone seems to be in agreement, however, that the proposal is, at very least, a step in the right direction.

“Mostly, though, it’s a symbolic and cheap step,” said Dr. Joel Lexchin, professor emeritus of health policy and management at York University. “It’s clear that the federal government has to get involved if we want coverage for drugs to match coverage for doctors and hospitals.”

The federal government, however, doesn’t appear to be interested in pursuing pharmacare at this time, and is focusing instead on reducing drug prices rather than increasing coverage, said Lexchin. That’s unfortunate, he said, because leveraging the bargaining power that comes with universal drug coverage is the best way to reduce drug prices.

Ontario’s pharmacare proposal is lacking because it fails to target the population most in need of assistance, according to Neil Palmer, founder and principal consultant for PDCI Market Access, a company that consults on pharmaceutical pricing and reimbursement. Many young people already have drug coverage through their parents, college, university or employer. The injection of $465 million into the annual drug budget is certainly welcome, but most low-income Ontarians who struggle with medication costs won’t see any benefit.

“A more targeted approach to extend coverage to those Ontarians under age 65 with the greatest need for drug coverage should be the objective,” said Palmer. “Unfortunately, a preoccupation with ‘universal pharmacare’ crowds out both pragmatic public policy and fiscal prudence.”

Though he puts himself in the supporter camp for the proposed policy, Arthur Sweetman, an economics professor at McMaster University and the Ontario Research Chair in Health Human Resources, also noted that youth don’t need or use prescription drugs as much as older people. Still, he noted, there would be many Ontarians under age 25 who will benefit. But so will people who don’t really need help.

“Not all, but many of the benefits, therefore, accrue to employers and workers at establishments where wages and benefits are reasonably good,” said Sweetman. “Of course, if this is indeed a first step among many regarding pharmacare, and if the next steps happen reasonably quickly, then those working poor not covered by this proposal, but who would have been covered by a differently targeted policy initiative, will be covered for the cost of pharmaceuticals in the not-too-distant future.”

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Indeed, you could think of the pharmacare proposal by the Ontario Liberal party as more of a symbolic gesture to shift the paradigm of drug coverage toward universality, according to Marc-André Gagnon of the School of Public Policy and Administration at Carleton University. The proposal put forth by the Ontario New Democratic Party, on the other hand, goes beyond symbolism, said Gagnon. That plan would see coverage of 125 “essential” medications from the 4400 on the province’s formulary for all residents under age 65, which would grant Ontario more bargaining power to reduce the prices of this smaller list of popular medications. But both plans, he noted, have their weaknesses.

“What is missing in the two proposals is a real alternative to private drug plans. In the two cases, the coverage proposed would complement existing private plans,” said Gagnon, noting that these private plans receive substantial tax subsidies. “These monies would be better used by financing universal public coverage instead of financing inequitable and inefficient fragmented private plans. We must stop thinking about drug coverage as a privilege offered by employers.”

Despite the limitations, however, the proposed plan, even if mostly symbolic, is positive incremental reform, according to Steve Morgan, a professor at the University of British Columbia’s School of Population and Public Health. It is better than nothing, he noted, and much better than shrinking public drug plans, as Quebec and British Columbia have done in recent decades.

Ontario has signaled that governments should take responsibility for this major component of health care, as they already do for doctors and hospitals. In essence, said Morgan, Ontario is calling on the federal government to use its medicare-like policy as a template for a national pharmacare program.

“Will this work? As a Canadian, I hope it does,” said Morgan. “As a student of health care policy and politics in Canada, I am not sure. Time will tell.”

Even if national pharmacare doesn’t become reality, or not for a long time, perhaps other provinces will follow Ontario’s lead and improve drug coverage for their residents, noted Dr. Danielle Martin of the Institute of Health Policy, Management and Evaluation at the University of Toronto.

“I also think it is a big improvement for young women in their teens and twenties in terms of access to contraception,” said Martin. “Since the budget also included funding for Mifegymiso, I think it is a pharmacare plan that is especially good for young women and reproductive choice.”

According to Dr. Leila Salehi, an adjunct assistant professor of family and community medicine at the University of Toronto, another strength of the Ontario proposal is what others have suggested is its main weakness: that it isn’t targeted to those most in need. An age-limited universal program may not provide the most benefit to the working poor, but it might have greater odds of succeeding, because it is easier to administer. Universal programs are more stable and efficient, with less ambiguity about who should qualify for coverage.

“Universal programs are far preferable to those that are means tested or targeted towards a specific, particularly vulnerable, segment of the population — primarily because, as the adage goes, programs for the poor are poor programs,” said Salehi. “Generally speaking, universal programs promise broad, strong political support — they confer a type of permanency and legitimacy that is lacking in means-tested programs.”

Photo credit: jonathansloane/iStock

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