Emergency pharmacare now
Medicine access is such a high priority during the COVID-19 pandemic that the Government of Canada introduced the Emergency Response Act that can override patents for COVID-19 treatments. Canadians will continue to need prescription drugs for other treatable conditions – such as cardiovascular disease, diabetes, airway disorders, infections, and serious mental health problems – that killed over 24,000 Canadians in 2017(1). Before the pandemic, cost-related medicine non-adherence was already more common in Canada than in other high-income countries, especially among low-income individuals and those without insurance (2). The COVID-19 pandemic will likely worsen access and widen disparities.
Measures taken to slow the spread of COVID-19 have resulted in over a million Canadian job losses to date and, with those jobs, many Canadians lost their employment-based private drug coverage. Emergency income supports such as the Canada Emergency Response Benefit (CERB) and changes to Employment Insurance provide the same supports regardless of medicine costs, and neither provide drug coverage. So, the new intensive care capacity built for COVID-19 patients could end up being filled by people having avoidable heart attacks and strokes. Poor chronic disease control may even worsen outcomes in those with COVID-19 as diabetes and hypertension are common among COVID-19 fatalities (3).
The midst of the pandemic may be the ideal time to act on recommendations of the Advisory Council on the Implementation of National Pharmacare that followed on the 2018 report of the parliamentary health committee that was titled “Pharmacare Now” (4,5). The Advisory Council recommended that national pharmacare begin in 2022 with a focus on a list of essential medicines, such as the one developed based on guidance from the World Health Organization (5,6). The 137 medicines on that list are widely used in Canada (7) and are already included in public formularies of provinces and territories for specific populations such as social assistance recipients (8). Results from studies of free distribution of medicines indicate that the short list will be acceptable to patients and clinicians in Canada, just as they are in dozens of other countries with essential medicines lists (7,9). Universal, public coverage of such a list could assist households with access and affordability while reducing drug benefit costs that have long been poorly controlled by the private sector in Canada (9,10).
The COVID-19 pandemic has shown that different levels of government can work together to help ensure certain standards are maintained across Canada. The history of Canadian Medicare also shows that governments in Canada can cooperate in such a manner over the course of many decades and in the face of many challenges. In exchange for federal funding provided through the Canada Health Transfer, provinces and territories agree to deliver medical and hospital insurance according to the principles of the Canada Health Act: universality; comprehensiveness; portability; accessibility; and public administration.
The federal government could establish an emergency pharmacare program in the same manner. It could be financed by way of a new, $3.5 billion annual transfer to provinces and territories. This amount of funding is sufficient to ensure that the federal government would be financing the entire incremental public cost of the program (5). Provinces would not be on the hook for any more than they would otherwise be paying for their existing public drug plans. Since coverage of the essential medicines list would be a universal benefit, it can be implemented quickly using existing public health cards and existing public drug plan claims processing systems.
Is a $3.5 billion outlay realistic as governments face massive deficits during the pandemic fallout? Yes, the need for such a program has never been greater and, unlike other health and economic investments being made during the pandemic like the CERB that will cost $22 billion (according to the Parliamentary Budget Office), universal public coverage of essential medicines will save Canadian businesses and households on the order of $2.7 billion to $5.8 billion per year more (9). Some of Canada’s cherished national social programs were created in the wake of previous global conflagrations. Taxation was centralized by the Government of Canada during World War II and the generated revenues were used, in the subsequent years, to help create our universal and publicly funded health insurance systems that are administered by provinces and territories. The COVID-19 pandemic may usher in new policies that have been discussed for decades such as pharmacare in Canada, just as Spain announced implementing an expensive basic income to meet a need made clearer by the pandemic.
A national pharmacare program could actually reduce the risk of shortages while increasing consumption. Drugs on the essential medicines list will be in increased demand by Canadians due to improved access – with increases in the use for particular drugs likely ranging from 10% to 20%, depending on the drug and substitutes in its class (7). Although existing pricing and supply agreements implemented by public drug plans would have to be used at the outset of the emergency pharmacare program, in the months that follow, price negotiations and supply management could be taken over by the nascent Canada Drug Agency – which can be created quickly given capacities in existing pan-Canadian agencies (5). This agency can help to ensure that Canadians have a secure supply of safe and effective medicines at the best available prices globally. A national approach to procurement would certainly be a safer bet than leaving individual provinces, territories, and private insurers to manage their own supply chains, sometimes in competition with each other.
Future waves of COVID-19 are anticipated and the economic impacts may last longer than the virus, so an emergency pharmacare program could be created to last for one or two years. The program could then be re-evaluated and shelved if unsuccessful or unexpectedly costly. Alternatively, the emergency program could be converted into a permanent policy that would involve a process for updating the list of included medicines and additional attempts to negotiate better prices and procure medicines more efficiently on an ongoing basis. Our new normal could involve equitable access to essential medicines including future treatments for COVID-19.
Competing Interests: The authors have no competing interests. All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Dr. Nav Persaud is Canada Research Chair in Health Justice and Associate Professor, University of Toronto Department of Family and Community Medicine.
Dr. Steven Morgan is a professor of health policy at the University of British Columbia. His research focusses on policies to provide universal access to appropriately prescribed, affordably priced, and equitably financed prescription drugs.
References
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2. 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 Jan;7(1).
3. Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. 2020 Apr;
4. Standing Committee on Health. Pharmacare Now: Prescription Medicine Coverage for all Canadians. [Internet]. 2018 [cited 2020 Apr 17]. Available from: www.ourcommons.ca
5. A Prescription for Canada : Achieving Pharmacare for All : Final Report of the Advisory Council on the Implementation of National Pharmacare. [Internet]. [cited 2020 Apr 17]. 172 p. Available from: https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advisory-bodies/implementation-national-pharmacare/final-report.html
6. Canada. Patented Medicine Prices Review Board. Alignment among public formularies in Canada. [Internet]. [cited 2020 Apr 17]. Available from http://www.pmprb-cepmb.gc.ca/view.asp?ccid=1327
7. Muhamad Z. Ally, Hannah Woods, Itunuoluwa Adekoya, Anjli Bali NPM. The acceptability of a short list of essential medicines to patients and prescribers: A multi method study of trial participants. 2020 Canadian Family Physician (unpublished, resubmitted with minor revisions 3 April 2020)
8. O’Brady S, Gagnon MA, Cassels A. Reforming private drug coverage in Canada: Inefficient drug benefit design and the barriers to change in unionized settings. Health Policy (New York). 2015 Feb 1;119(2):224–31.
9. 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 [Internet]. 2017 Feb 27 [cited 2020 Apr 17];189(8):E295–302. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28246223
10. 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: The CLEAN Meds Randomized Clinical Trial. JAMA Intern Med 180(1):27–34.
