Introduction

Canada is the only country in the world with a universal public health system and no accompanying universal Pharmacare system [1]. Canada’s current prescription drug coverage is funded by a mix of public and private plans with high variability between provinces, leaving many Canadians with little to no coverage [2]. One in 10 Canadians have reported not being able to afford their prescribed medication [2]. In contrast, one in 50 United Kingdom residents have reported this same barrier despite having a healthcare system analogous to Canada [2]. The literature has shown that Canada has the second highest national prevalence of cost-related non-adherence (CRNA) to prescription medications (8.3%), falling only behind the United States (USA) (16.8%) [3]. The COVID-19 pandemic has magnified this issue. In May 2020, the Canadian unemployment rate was 13.7%, double the rate of the year prior [4]. 53% of Canadians rely on their employer benefits to receive their pharmaceuticals [4]. This loss of employment will ultimately lead to a loss of these benefits and a subsequent inability to purchase medications. Individuals will be forced to compromise their health in order to afford necessities of daily living or compromise basic necessities in order to afford medications. In order to improve the health of Canadians, a universal Pharmacare program must be implemented.

Intervention

In order to address financial barriers to medications, a single national drug agency and an essential medicines list consistent across all provinces is required. Over 110 countries around the world have one small essential medicines list that is tailored to their country’s needs, whereas in Canada, these essential lists are long and will vary by province [5]. For instance, the Ontario Drug Benefit formulary is 4000 items long, whereas Sweden’s “Wise List” is approximately 200 items long [5]. These shorter evidence-based, context-driven and cost-effective formularies are needed improve Canada’s healthcare system [5]. By concentrating the price competition on a small selection of medications, the cost of medications will decrease, making a universal program feasible. Every two years, the World Health Organization (WHO) publishes an essential medical items list to act as a guideline for every nation to follow, with the most recent list containing 448 items [5]. Taglione et al. [5] narrowed this list down to 108 medications by adding and removing medications based on Canadian clinical practice guidelines, systematic reviews, and usage statistics in Canadian healthcare practice. When two primary care sites in the Toronto region (St. Michael’s Hospital and North York General Hospital) were audited to observe how well the new list covered prescription requests, the list was able to cover 90.8% of St. Michaels and 92.6% of North York’s most commonly prescribed medications. In addition, the list provided total drug coverage for 73.4% of St. Michael’s and 79.8% of North York’s patients. Morgan et al. [6] applied this list to the National context and found that the list covered 50% of publicly paid prescriptions and only required 31% of the total expenditure on publicly paid prescriptions from previous years. The new list removes redundancies (medications that had the same indication as other listed medications) in order to create a compact, yet comprehensive list. This list can be used as a framework for creating one national Pharmacare program that is economically feasible and safe for Canadians.

Improved prescription practices

Through one national Pharmacare program, safer clinical and public health practices will emerge. Private plans in Canada have been shown to provide coverage for medications with poor risk-benefit ratios [7]. Clinicians must follow these plans, prescribing suboptimal drugs to patients in order to meet budget demands set by private insurance agencies [7]. A study conducted by Samoy et al. [8] in the Vancouver General Hospital showed that 24.1% of hospitalizations were drug-related and 72.1% of admissions were preventable with more appropriate prescribing practices. The use of one national formulary comprised of the most effective medications can lead to improvements in prescribing practices, mitigating prescription drug-related adverse events. Furthermore, one national program lays a foundation for the development of a national drug monitoring database. Canada’s current healthcare system relies on the surveillance of multiple institutions including pharmacy retailers, private insurance companies and various levels of government [9]. This fragmented system leads to poor surveillance quality, and subsequently poor practice guideline development [9]. One national system could drastically improve the quality of Canada’s surveillance quality, thus improving prescription practices.

Improved adherence to prescription medication and decreased financial strain

The addition of a universal Pharmacare program will eliminate the financial barrier on drug access in low socioeconomic (SES) populations in Canada, leading to decreased financial strain, better adherence to prescribed medications and subsequently better health in these populations. In 2016, an estimated 1.45 million Canadians reportedly spent less on basic living necessities such as food and heating to cover the cost of their prescriptions, with a majority of the reports coming from individuals of lower incomes (less than $40,000) and no drug coverage [10]. Canadians who have had the opportunity to participate in universal Pharmacare mock research trials stated that the intervention periods alleviated financial problems, allowed them to “make ends meet,” and that they ‘dreaded’ the lack of drug coverage after the intervention periods [11]. Failing to take prescribed medications on a regular basis has implications for adverse health events, warranting increased physician visits or admission to hospital that would not have been required with free access to medications [10]. Increased drug coverage can drastically reduce these adverse events and improve quality of life. Research conducted in the USA demonstrated an 11.6% decrease in reports of drug-related CRNA, resulting in a six percent decline in emergency department visits in two years when Medicaid provided coverage for drugs in Kentucky, Arkansas and Texas [12]. Recent studies conducted in Ontario found that free access to essential medications could increase drug adherence by 11.6%, resulting in a significant decrease in blood pressure in those who were prescribed antihypertensive medications when compared to those with no access [13].

Financial saving in various government sectors

Canada has been reluctant to start a universal Pharmacare program because of concerns regarding incurring costs associated with the program [6]. The projected cost of implementing a universal Pharmacare program would increase the current total spending on pharmaceuticals by $1.23 billion each year [6]. However, savings in various sectors of the healthcare system outweigh this incremental increase. The private and public health sectors would save a projected $4.37 to $9.4 billion in the worst- and best-case scenarios [6]. These savings do not include indirect savings from various sectors outside of healthcare. Increased access to pharmaceuticals and improved prescribing practices with the new national formulary mitigates drug-related adverse events and subsequent hospital admissions, saving approximately $5 billion each year [6]. Since all administration responsible for Canada’s drug distribution is housed under one national program rather than under multiple organizations, administration costs are projected to decrease by an estimated $1-2 billion each year [6]. Improved adherence to medications that were deemed unaffordable pre-Pharmacare would save approximately $1-9 billion each year through improved preventable disease management, increased work productivity, and less disease-related absences [7]. This translates to savings for Canadian taxpayers and businesses that are providing drug coverage that could be better spent elsewhere.

Conclusion

COVID-19 has augmented the effects of Canada’s lack of drug coverage, a problem that had existed long before the start of the pandemic. An overwhelming amount of research has demonstrated that a universal program is feasible in Canada, and the health benefits associated with its implementation are evident. Through the implementation of a universal program prescription practices become safer, there are improvements in drug adherence, and the cost of prescription drug coverage decreases, resulting in savings at multiple levels of government. All of these ripple effects ultimately lead to better health and quality of life for Canadians. By following the steps of other successful countries, Canada will finally be considered a country that truly provides universal health care.

References

1. The Lancet. Canada needs universal pharmacare. Lancet. 2019;394(10207):1388.
2. Morgan SG, Law M, Daw JR, Abraham L, Martin D. Estimated cost of universal public coverage of prescription drugs in Canada. CMAJ. 2015;187(7):491-497.
3. Morgan SG, Lee A. Cost-related non-adherence to prescribed medicines among older adults: a cross-sectional analysis of a survey in 11 developed countries. BMJ Open. 2017;7(1).
4. Lau D, McAlister FA. Implications of the covid-19 pandemic for cardiovascular disease and risk-factor management. Can J Cardiol. 2020.
5. Taglione MS, Ahmad H, Slater M, Aliarzadeh B, Glazier RH, Laupacis A, et al. Development of a preliminary essential medicines list for Canada. CMAJ Open. 2017;5(1).
6. Morgan SG, Li W, Yau B, Persaud N. Estimated effects of adding universal public coverage of an essential medicines list to existing public drug plans in Canada. CMAJ. 2017;189(8).
7. Minhas R, Ng JC, Tan J, Wu H, Stabler S, Beach J, et al. Should developed countries, including Canada, provide universal access to essential medications through a national, publicly funded and administered insurance plan? Can J Hosp Pharm. 2016;69(2).
8. Samoy LJ, Zed PJ, Wilbur K, Balen RM, Abu-Laban RB, Roberts M. Drug-related hospitalizations in a tertiary care internal medicine service of a Canadian hospital: A prospective study. Pharmacotherapy. 2006;26(11):1578-1586.
9. Morgan SG, Martin D, Gagnon MA, Mintzes B, Daw JR, Lexchin J. Pharmacare 2020: The future of drug coverage in Canada. Vancouver: Pharmaceutical Policy Research Collaboration, University of British Columbia; 2015.
10. Law MR, Cheng L, Kolhatkar A, Goldsmith LJ, Morgan SG, Holbrook AM, et al. The consequences of patient charges for prescription drugs in Canada: A cross-sectional survey. CMAJ Open. 2018;6(1).
11. Yaphe H, Adekoya I, Steiner L, Maraj D, O’Campo P, Persaud N. Exploring the experiences of people in Ontario, Canada who have trouble affording medicines: A qualitative concept mapping study. BMJ Open. 2019;9(12).
12. Sommers BD, Blendon RJ, Orav EJ, Epstein AM. Changes in utilization and health among low-income adults after medicaid expansion or expanded private insurance. JAMA Intern Med. 2016;176(10):1501.
13. Persaud N, Bedard M, Boozary AS, Glazier RH, Gomes T, Hwang SW, et al. Effect on treatment adherence of distributing essential medicines at no charge. JAMA Intern Med. 2020;180(1):27.