Jeffrey Simpson has been the national affairs columnist for the Toronto Globe and Mail for almost three decades. Since the turn of the new century, Simpson has written numerous critical columns on the state of health care in Canada. He has not only been a reliable weathervane for the changing critique of medicare but, as a leading mainstream journalistic voice in English Canada, he also shapes the views of his readers. It is not surprising, therefore, that considerable attention has been lavished on his latest book, Chronic Condition.

The good news is that the book goes beyond simply rehashing Simpson’s past critiques. More space is devoted to the facts – the statistics and individual stories on which Simpson builds an argument for major change. The bad news is that on the basis of these facts Simpson ends up drawing some very questionable if not erroneous linkages, and this puts into serious question both his diagnosis and his policy cure for what ails Canadian medicare.

Since the 1990s, a stream of books and think tank essays have criticized the Canadian model of universal, tax-financed medicare. At first the critics argued for more private delivery of government-financed medicare services. This was always a red herring given that in Canada the vast majority of doctors and their clinics are private for-profit operators. And while it is historically true that most hospitals in Canada were owned by religious orders, charities and municipalities and hence were not-for-profit, they were not owned by provincial governments. This has changed somewhat with the introduction of regional health authorities in the 1990s, but in some provinces, such as Ontario, hospitals remain private not-for-profit organizations separate from government. In any event, there is nothing in the Canada Health Act that prevents provincial governments from allowing the private delivery – for-profit or not-for-profit – of medicare services

By the 2000s, the brief against medicare had shifted to the single-payer model of funding. This became most obvious in the 2005 Chaouilli decision by the Supreme Court of Canada. A slim majority held that the government of Quebec could not hold a “monopoly” on funding health services if it permitted wait times for surgery that might put patients at risk. In such situations, provincial residents should have the right to purchase private health insurance permitting them to obtain more timely health services. Although Chaoulli was not the killer punch to medicare that proponents had hoped, other cases have been launched that strike at the heart of the Canadian model of medicare.

In fact, the antimedicare coalition has become ever more vocal since Chaoulli. And its activists are willing to back up their beliefs with hard cash: they conduct expensive litigation and fund think tanks such as the Fraser Institute, which has led the charge in favour of private delivery and private health insurance. Recently, Dr. Brian Day – the medical profession’s most outspoken critic of medicare – and his Cambie Surgeries Corporation in Vancouver have sued the government of British Columbia on the grounds that its single-payer administration of medicare (and therefore all provincial and territorial models of medicare) is a violation of sections 7 (individual right to life, liberty and security) and 15 (individual right to equal protection and equal benefit) of the Canadian Charter of Rights and Freedoms. The case will be winding its way through the B.C. courts to the Supreme Court over the next two to three years and will no doubt trigger further debate on the Canadian model.

I have no argument with Simpson’s basic contention that Canada has slipped on a number of health and system performance indicators in the last two decades. At the same time, other facts demonstrate the situation to be not nearly as dire as Simpson has presented. This is not to defend the status quo – far from it. In almost everything I have written in the past decade, I have argued that we can and should do better, but we have got some things right, and we should build from these strengths. At the same time, we need to identify the institutional impediments to progress and be prepared to make major changes irrespective of those interests that are vested in the status quo.

Is the system fiscally sustainable?

Let me start with the issue of fiscal sustainability. Simpson is correct that health care has been eating up an increasing proportion of provincial government budgets in the years following the fiscal retrenchment in the mid-1990s. This has put considerable fiscal strain on the provinces.

However, since 2000, governments have chosen to reduce taxes and, at least in the case of the federal government, increase tax expenditure subsidies. In other words, they have reduced the denominator even as the numerator needed to increase – after a half decade in the mid-1990s during which Canadian governments drastically restricted health spending. Putting the revenue issue aside, where does Canada sit, comparatively speaking, on the expenditure side of the equation? Is Canadian spending on health care truly unsustainable relative to similar OECD countries?


Figure 1 plots per capita growth in public health expenditure against per capita growth in GDP for all OECD governments spending more than US$2,000 on health care in 2008. Only in Germany and resource-rich Norway did health spending not grow more rapidly than per capita GDP during this decade. In fact, Canada lies slightly below the trend line (defined by regressing growth rates of per capita health expenditures on growth rates of per capita GDP). On the basis of this evidence, Canada could hardly be considered profligate in its government health spending.1

Simpson’s diagnosis is that health spending will continue to rise because in “the self-absorbed world of health care, it is just assumed by those employed in the field and by the experts that marginal government dollars, if they are available, should go into health care” thereby trumping every other government program. While health care envelopes did receive preferential treatment in provincial budgets from the late 1990s, governments are now pushing back. Public sector health expenditures in Canada grew at a nominal rate of 7 per cent from 2000 until 2010; this growth rate has dropped considerably since 2010. The nominal 2011–12 growth rate of provincial and territorial health spending plummeted to 2 per cent.

Physician remuneration has been the most inflationary sector of health care in the last six years, outstripping even prescription drug spending, which had been the fastest-growing sector in health care since the 1970s.2 Few government leaders have failed to realize that fee schedules and other forms of doctor remuneration were spinning out of control. Which explains why, in the past year, Ontario and Alberta have confronted their medical associations. Likewise, the halcyon days of overly rich collective agreements with nurses’ unions are over. Provincial governments are finally implementing cost control on generic drugs in a country that pays among the highest prices in the world for pharmaceuticals.

Putting aside the self-interest of providers for the moment, Simpson seems to have little confidence in governments’ ability to contain costs and in the general public’s ability to elect governments that will act in its best long-term fiscal interests: “Dreams permeate Canadians’ thinking about medicare, and no politician wants to shatter them.” He sees the relationship between the two as codependent: the public demands that governments provide as much “free” health care as possible while governments hide the true cost, scrambling every year at budget time to rob other programs and services to pay for mounting health care budgets. In this narrative, both are responsible for building a Ponzi scheme that will inevitably collapse. On the basis of figure 1, I can only assume that Simpson would apply the same narrative to all OECD countries, with the possible exceptions of Germany and Norway.

I suggest an alternative narrative, one that gives Canadians and their governments a little more credit for intelligence. Although Canadians receive first-dollar coverage for medically necessary hospital and physician services, they do understand that many of these services are very expensive and they (mostly) want their governments to get as much value as possible for every dollar spent. For the many health services outside the medicare basket, Canadians are already paying more out of pocket or through employment-based private insurance than the citizens of most OECD countries.

Provincial governments demonstrated their ability to contain costs in the mid-1990s, and as public resources become tighter they will do so again. They are already starting. However, having learned a few lessons from the last time they applied the brakes, provincial governments will be more careful to find savings that will actually improve the efficiency of the system, not simply reduce public health-care costs in the short run by shifting costs from public to individual pockets. Contrary to Simpson’s view, provincial governments may reexamine the revenue side of the picture, and raise taxes in a careful manner. Voters realize that you cannot have European-style social benefits at American tax rates. As for health providers, of course they will continue to seek higher remuneration (as we all do), but we can expect provincial governments beyond Ontario and Alberta to be more aggressive in ensuring that increases for health providers no longer outstrip gains in the rest of the public sector.

Health outcomes: From the burden of disease to amenable mortality

Scattered throughout Simpson’s book are references to the fact that some OECD countries spend less money on health care yet have better health outcomes than Canada. Unfortunately, without endnotes or a proper list of references I cannot trace his data sources. No matter. Let me turn to the most recent and reliable comparative analysis on the burden of disease, published in The Lancet, one of the most prestigious medical journals in the world.3

There are three striking results. The first is that all OECD countries have seen improvements in terms of the burden of disease. Any change in ranking is the result of how fast countries have improved. The second is that in this 19-country comparison, Canada has extremely good health outcomes as measured by the roll-up measure of health-adjusted life years (HALE).4 Finally, it is worth noting that Canada has slipped from second position in 1990 to fifth in 2010. Canada still stands up well relative to the United Kingdom (12th), the United States (17th) and most northern European countries, including Nordic countries such as Norway (16th), Denmark (18th) and Finland (19th). While a decline in rank of three positions in two decades might not seem precipitous, the HALE result obscures a more troubling trend. We can see this in terms of Canada’s rank decline for life expectancy at birth.


Unfortunately, burden of disease statistics can tell us little about the performance of the health care system. It is extremely difficult to assess the precise contribution of programs, policies and medical interventions to health outcomes. Simpson too readily uses simple indicators such as life expectancy as evidence of poor health system performance in Canada.

To create a more direct linkage, health system researchers have defined the concept of amenable mortality (AM) to isolate the impact of the health system from the other determinants of health. Amenable mortality refers to death from selected diseases where death would not occur if those individuals had access to timely and effective care. By isolating where death could be avoided and the condition in question treated, amenable mortality seeks to capture the extent to which a health system has or has not been effective. The index itself is based on a host of age-standardized AM death rates per 100,000 that are aggregated into a single scale.

On the basis of an amenable mortality index developed by Ellen Nolte and Martin McKee,5 Canada ranked sixth (after France, Japan, Australia, Spain and Italy) among 19 high-income OECD countries in 2002–03. In contrast, the United Kingdom ranked 16th and the United States 19th. A subsequent OECD study based on the Nolte and McKee approach showed roughly similar results for a larger sample of 31 OECD countries. The results? France was again at the top; Canada was 11th, the United Kingdom 19th and the United States 24th, near the bottom.6 While Canada’s ranking is respectable, it does show some slippage, and we should be working toward a better performing system.

Canada’s poor performance in primary care

So what is preventing better performance? Simpson points to a scattering of causes but considerable evidence suggests that the poor quality of primary care in Canada is a major cause. In any event, primary care forms, or should form, the spine of most health systems. Poor performance in this sector has a potentially large impact on other sectors. As in Britain (but not the United States), primary care physicians in Canada act as gatekeepers in terms of referrals to specialists and further diagnostic tests. In addition, primary care physicians are responsible for prescribing the majority of prescription drugs.

Simpson relies heavily on a group of comparative studies of OECD countries conducted by the New York–based Commonwealth Fund to make his case that health care in Canada performs poorly. These studies, based on the self-reported perceptions of patients and physicians, are important evidence, but I think they are mainly informative about the state of primary care. Canada had the poorest outcomes in terms of access to a doctor or nurse and, consequently, greater reliance on the use of hospital emergency departments.7 The 2011 survey of sicker patients reflected poor coordination between primary care physicians and consultants. Canada’s middling performance in terms of coordination – at least as perceived by patients – stands in stark contrast to, for example, the United Kingdom’s much more positive outcome on this indicator.8

So, why does Canada compare so poorly to other OECD countries in terms of primary care? There are at least two institutional reasons. The first can be traced back to the initial introduction of universal medical care coverage (as opposed to hospital coverage) by Saskatchewan in 1962. At the time, the majority of provincial physicians opposed introduction of a universal single-payer scheme for all medically necessary services provided by physicians. They were joined in their opposition by organized medicine throughout Canada as well as the American Medical Association. A 23-day doctors’ strike ensued, which was only brought to an end with a compromise that protected the status of all doctors as independent contractors paid through fee-for-service. This compromise – known as the Saskatoon Agreement – subsequently became the social compact for universal medical care insurance in the rest of Canada.9

Fee-for-service has encouraged volume-driven, transactional practice not generally suited to primary care, which requires time to assess, diagnose and treat patients, to discuss and evaluate patient histories, and to encourage patients in illness prevention and health promotion activities and behaviours. In addition, since fee-for-service reimbursement was restricted to doctors, it has made it very difficult for provincial ministries to finance a team-based and interprofessional approach to primary care.

By the beginning of the 21st century, the lack of progress on primary care reform was obvious to experts and governments in Canada.10 Primary care was identified as a national priority by federal, provincial and territorial governments in 2000 and 2003, and the federal government provided money to provincial governments and organizations initiating reform. In 2004, in return for a long-term commitment for federal transfers for health care, the premiers signed a 10-Year Plan to Strengthen Health Care, agreeing to work on ensuring that at least 50 per cent of Canadians would receive 24-hour-a-day, seven-day-a-week access to team-based primary care by 2011. This goal was not achieved, an unsurprising result given the lack of agreement on how to achieve it and the institutional interests committed to the status quo that provinces would have to confront.

While experiments in primary care reform have been scaled up, no provincial government has changed the fundamental governance of primary care. The vast majority of physicians remain independent contractors with the provincial ministries of health, and despite major payment reforms, in Ontario for example, most family doctors in Canada continue to receive most of their remuneration as fee-for-service payments. Regional health authorities are being held responsible for administering most health services, but have no effective control over, or responsibility for, the crucial component, namely primary care physicians.


Like Simpson, I think that there is considerable room for improving both coverage and cost containment for prescription drugs. To achieve this goal requires major structural change. I have previously argued in this magazine for a national pharmacare program,11 with which Simpson seems to have some sympathy. Here, there could be a real role for the federal government given its constitutional foothold in administering patent law, in determining whether drugs can be marketed on the basis of safety considerations, in regulating patented drug prices and in monitoring generic drug prices.

At the same time, provincial governments cannot realize sufficient scale economies to exert effective bargaining leverage with the pharmaceutical industry. They face a phalanx of interest groups, including the disease groups that target governments to place drugs with a questionable cost-benefit ratio on their respective formularies. Provinces are easily played off against one another as new drugs or me-too drugs enter the market. As a result Canadians are paying among the world’s highest prices for generic drugs. While the retail prices of branded prescription drugs are more in line with OECD averages, we rarely take advantage of bulk purchasing discounts, a common practice in the United States. Many Americans with good health plans pay far less than retail for their drugs, leaving the poor and uninsured paying the highest drug prices.

In other words, we could readily increase value for money if our federal and provincial governments could agree on Ottawa’s taking on this responsibility. The problem is that neither the Harper government nor the preceding Martin government has seen any advantage to taking on the risk of funding, administering and managing a national pharmacare program. Still, this change should be put on the policy agenda by a motivated general public and a perceptive opposition party.

Is medicare really the problem?

The evidence on fiscal sustainability, the burden of disease and overall system performance as measured by amenable mortality demonstrate that Canada is doing better than Simpson argues. At the same time, I agree with him that we could be, and should be, doing much better. But what exactly should we be doing?

Simpson believes the main problem is the self-destructive, even deceptive, behaviour of governments and the Canadian public. Presumably, he wrote in order to persuade governments and the general public to think more clearly and honestly about the issues, the implication being that the behaviours of both will change for the better once they syop hiding from the “truth.” However, Simpson’s fundamental truth seems to be that medicare itself is fundamentally flawed: by offering health care free at the point of service, we encourage excessive demand. He raises questions throughout – although his arguments are more implicit than explicit – about universality and single-payer administration.

In contrast, I believe single-payer administration has been a strength of the Canadian system. While medicare is narrowly delimited to medically necessary hospital, diagnostic and medical services, single-payer administration keeps overhead costs to a minimum compared to the options of private and social health insurance. This is a great advantage, which we should hang on to and potentially expand to services such as pharmacare.

When we launched medicare in the 1960s, we got the universality right. To move to targeted benefits would not only cost more (as our provincial prescription drug programs demonstrate) but would undermine a key value that Canadians see as part of their identity. Simpson doubts the viability of first-dollar insurance, but basing access on medical need rather than ability to pay, though currently restricted to medicare, is a laudable and sustainable goal. While there is some potential for abuse, most individuals do not want to go to the hospital or submit to diagnostic tests, and will not do so unless advised by a physician. If there is overuse, it lies more with physicians than patients, and it cannot be addressed through patient user fees. As for primary care, we should encourage individuals to use this relatively inexpensive upstream service in order to reduce downstream hospital and institutional care. Easy access to primary care is not what needs to be changed.

However, we do need to revisit one important dimension of medicare. The Saskatoon Agreement has outlived its usefulness. According to the Commonwealth Fund surveys, Canada has among the poorest primary care outcomes in the OECD. To move up the ranking we must change the governance, accountability and payment regimes for primary care physicians.

Continue reading “Medicare in the crosshairs”

Paul Starr,
Remedy and Reaction: The Peculiar American Struggle over Health Care Reform
New Haven and London: Yale University Press, 2011

324 pages

Paul Starr is a professor of sociology and public affairs at Princeton University. In 1982, he published The Social Transformation of American Medicine, a masterful two-century history of the American medical profession and the health care system. The book went on to win a Pulitzer Prize. In 1990, along with Robert Kuttner, he founded The American Prospect, a magazine that has attempted to fight the powerful neoconservative tide in the United States by presenting proactive and workable “liberal” policy alternatives. Three years later, Starr left the ivory tower for a short time to become a senior adviser to Bill and Hillary Clinton in their ill-fated health reform effort.

Remedy and Reaction, Starr’s most recent book, is the best analysis so far of the tortuous evolution of health reform in the United States. He focuses almost all his attention on the last two decades, from the failed Clinton reform in the 1990s to the 2008 nomination and election debates that led to Barack Obama’s Affordable Care Act of 2010. From the beginning, Starr has maintained that medically necessary health care is a critical aspect of what he calls “human development and security” and should be a right of citizenship. Pointing out the “peculiarity” of the American case, he argues that the inability to accept health care as a right and achieve universality makes the United States an anomaly among wealthier industrialized countries.

More significantly, he concludes that his country is also internally inconsistent. Strangely enough, Americans long ago accepted that access to education was a right. They also agreed that providing the elderly and disabled with economic security was a universal right. Yet when it comes to basic health care, the debate continues to be polarized because of the number of Americans who continue to see access to medically necessary care as something that should be earned privately. Figuring out why citizens who assume that there is nothing wrong with treating education and old age pension security as a collective right reject the same principle for health care is the central question of this book.

Indeed, until the Clinton effort in the 1990s, there was no real attempt to achieve universality: “Franklin Roosevelt put off proposing national health insurance because he wasn’t willing to take the political risk it entailed; Harry Truman endorsed the principle but never submitted legislation, knowing it was certain to be defeated.” Lyndon Johnson, accepting private employment insurance as the foundation of the American health system, patched that system with two targeted programs. Seeking to fill in two of its largest cracks, Johnson sponsored Medicare and Medicaid in 1965.

A federal social security program, Medicare provided health insurance to Americans aged 65 and older who made a minimal contribution through social security during their working lives. A combined federal-state program ensuring access to the most basic health services, Medicaid was for the very poor – those without jobs or the occasional low-paid job without health benefits. The unintended consequence of these programs was to create a “policy trap” – Starr’s phrase – at both state and federal levels that would make it almost impossible for health care to become a universal right in any individual state, much less the country as a whole.

First of all, both programs reinforced the centrality of employment-based insurance with its opaque funding divided between employers and employees, and related tax expenditure subsidies provided through governments. The end result was a lack of transparency concerning the actual value for money of private health insurance as well as the extent to which public revenues are used to subsidize private health insurance, often for Americans who least need government subsidies.

Medicare in particular created a new set of stakeholders who believed that they earned the right to Medicare coverage (though many only paid a fraction of the actual cost) and should not be obliged to pay for anyone else. After Medicare had become an established part of the policy landscape, middle- and higher-income retirees with Medicare coverage became as fearful as corporate executives and union members with private health benefits about the possibility of having to give up some of their gold-plated coverage to pay for a more basic universal coverage plan.

In this narrative, it would be convenient but misleading to draw a straight line from Johnson to Clinton. Separating the two was the counterrevolution triggered by Ronald Reagan and a growing scepticism about the positive role of government (particularly the federal government) or even the notion of a public (as opposed to private) interest. At the same time, Reagan’s trickle-down philosophy and tax breaks for the wealthy exacerbated the gap between rich and poor, making America a far more unequal and polarized society. As a result, by the late 1980s access to basic health care had become an even more salient problem than it had been in the 1960s, and the public began to demand redress.

This spurred individual states to attempt to introduce universal health care schemes, some on a Canadian-style single-payer model. All failed, including the one state – Vermont – in which there seemed to be a broad consensus that a single-payer system was the best way to go. This failure was due in large part to the lack of support from key interests that personally benefited from the policy status quo even if Americans collectively were paying much more than citizens of countries with universal and comprehensive health coverage for a fragmented system of partial coverage with some of the poorest health outcomes in the OECD.

Despite these failures on the state level, when Bill Clinton was elected President in 1992 momentum toward major health system reform seemed to be growing. As a “new” Democrat, Clinton drew a distinction between his administration and “tax and spend” Democrats of the past including Roosevelt and Johnson. Inheriting a huge public deficit due to the previous decade of Republican tax cuts and high military spending, he resolved to fix the country’s finances, and saw health reform through the lens of reducing public health care expenditures. His health package – Starr makes it clear that it was his plan far more than Hillary Clinton’s – was based on the continuing primacy of private insurance and regulation rather than direct state intervention.

Despite his own role at the time, Starr is dispassionate and direct about the failures of the Clinton effort in the early 1990s. He attributes these failures not to the administration’s inability to explain the complex plan to Americans, nor to the sustained and well-financed opposition of hostile stakeholders such as the health insurance industry with its infamous Harry and Louise ads. Rather, the Clinton effort failed because of a shift by the Republicans. He points at Bill Kristol, a key Republican strategist, and Newt Gingrich, who together were responsible for convincing the majority of Capitol Hill Republicans to embrace a scorched-earth strategy of refusing to negotiate meaningfully on health care legislation.

Although this same strategy also came within a whisker of defeating President Obama’s Affordable Care Act in 2010, the difference this time was that Obama managed to mollify some of the most important interests, in particular Big Pharma and the hospital industry. But his administration could only do so by compromising on cost containment and by watering down what was already “minimally invasive” health reform. What Starr means by this memorable phrase is that the program design, based on individual rather than employer mandates, is phased in over several years to avoid disrupting the health insurers, the hospitals and the pharmaceutical companies. At the same time, it will only increase coverage from 83 to 94 per cent – still well below universal coverage. And access to basic health care is still not a legislated right in the United States, although the basis on which (most) lower-income Americans can purchase health insurance has improved.

Obama paid a very high political price for what seems an anemic victory. More important, the weaknesses of the Affordable Care Act may lead to a loss of support among the very constituencies that originally supported the change. While the act can only help the insurance and medical industries – more access means higher utilization and the means to pay the bills – it may be bad for business if the cost of insurance continues to grow exponentially. It will also be bad for all American taxpayers if they have to pay for the federal government’s inability, and state governments’ lack of incentive, to bend the cost curve. Finally, I am sure the progressives who held their noses and fought in favour of the act will also be disappointed if the reform does not lead to universality, defined in the simplest of terms as 100 per cent coverage.

According to Starr, Clinton’s health policy brains trust was highly influenced by a natural experiment. Before Canada’s introduction of universal medical care insurance in the late 1960s, both countries were on the same trajectory in terms of health care costs. More than two decades later, while American health costs soared above those in every other wealthy industrialized country, Canadian health spending had moved to the centre of the pack of rich countries even while providing universal coverage. The policy lesson from my perspective is that single-payer systems are considerably less expensive than multipayer insurance systems. Why? Because they eliminate all the administrative costs associated with assessing and monitoring risk and the administrative overhead associated with repaying patients and providers.

However, we Canadians should not assume we are above the interest group politics that bedevilled U.S. attempts to achieve universal health insurance. We have been unable to engage major reform on the financing side since we introduced universal hospital and medical (i.e. physician) coverage, in part because we are caught in our own policy trap. The most powerful stakeholders in our system include regional health authorities, hospitals (at least those that remain independent), physicians and nurses. The latter groups benefit from the privileged treatment of hospitals and consistently goad the federal, provincial and territorial governments to devote ever more resources to the existing core “medicare” budgets. They do not goad governments to address the holes in our system.

Although forced out of the hospital and physician business, insurance companies have found a lucrative niche in ensuring dental and prescription drug coverage in particular. Middle- and upper-income Canadians are amply taken care of by premium employment-based insurance coverage. As a consequence, we have among the poorest dental care access in the OECD yet almost no constituency urging politicians to address the problem.

In a microcosm of the American health system as a whole, our federal, provincial and territorial drug plans attempt to fill in the holes left by multipayer employment-based insurance systems. Yet the current fragmented and expensive system – Canada has among the highest-cost prescription drugs in the world – remains in place because it benefits pharmaceutical companies. As for the rest of us, we take no heed of the actual cost, buried in tax expenditures and employer contributions. Until Canadians address these deficiencies in our own system, we have no reason to be smug in looking at health care politics in the United States.

Prescription for an ailing federation?

For the past six years, health care has been at the top of the federalism music chart. During this time, first ministers’ meetings have become a set piece. Before the meeting is called, the premiers demand more money for health care from Ottawa – knowing that they will not get what they are asking for. The prime minister brushes off these initial demands in public, but meanwhile the federal government enters into private negotiations with the provinces to reach an agreement. Once the dollar figure is in the federal ballpark, the prime minister schedules a formal meeting.

The exception to this pattern was the September 2004 first ministers’ meeting that produced the so-called “Ten Year Plan to Strengthen Health Care.” In contrast to earlier meetings, Prime Minister Paul Martin made no real attempt to get even a rough agreement in advance. The premiers went into the meeting with their largest-ever demand: that the Prime Minister put enough money into the Canada Health Transfer to close what they called “the Romanow gap” (see glossary on page 96) and that the federal government also take over provincial drug plans. While no precise dollar figure was produced for the drug proposal, the provinces were in effect asking Ottawa to pony up close to $8 billion annually, the amount they were collectively spending on prescription drugs for their respective residents.

At the time, Premier Ralph Klein of Alberta congratulated himself and the other premiers for their “stroke of brilliance.” Indeed it might have been, but only if the premiers had walked in with a workable blueprint of how such a major innovation would improve prescription drug coverage at a reasonable cost and simultaneously facilitate health reform. Instead, they came to the first ministers’ meeting without even a sketch of what a federal pharmacare program would look like, much less accomplish. They thereby confirmed the sceptics’ conclusion that the premiers’ offer was about cost-shifting, not about improving health care for Canadians.

Given the ephemeral nature of the provincial pharmacare proposal, it was relatively easy for Martin to brush it aside and focus on the reduction of wait lists. This was the item at the top of his agenda, even though it fell entirely within provincial control and jurisdiction. On the pharmacare proposal, the Prime Minister stuck to the short-term recommendations in the Romanow and Senate reports of 2002, and asked that some of the federal money be used to improve catastrophic drug coverage while shunting consideration of the pharmacare proposal to a federal-provincial ministerial committee. Here, it will be dead easy – and publicly justifiable – for Ottawa to veto any ambitious proposal on federal pharmacare given the already huge amount that it is transferring to the provinces as part of the Ten Year Plan deal.

13 Figure 1It is also unfortunate. Only by transforming public drug policy will we be able to tackle the real sustainability problem in health care. Going one step further, by initiating major reform to the way in which drugs are currently prescribed and used, we can dramatically improve primary care, home care and long-term chronic care. Without major changes to our federal-provincial arrangements for the administration, delivery and funding of public prescription drug programs, we are unlikely to ensure “that the right patients are getting the right drugs … at the right price,” at a reasonable and sustainable cost to governments and taxpayers.1 Drugs already constitute the second biggest piece of the health care pie, less than hospital care but more than physicians’ care (see figure 1).

The Romanow Commission laid out an incremental strategy to achieve significant change in how we organize the use of pharmaceuticals in the provision of health care. The catastrophic drug transfer program it recommended was to be only the first step toward creation of a National Drug Agency, establishment of a national drug formulary, introduction of more effective management and monitoring of drug utilization, and regulatory changes aimed at lowering the price of generic drugs and limiting the inflationary impact of new patented drugs.2

There has been little to no movement on this transformative agenda, in part because of the current division of responsibilities for prescription drug care. The federal government has virtually all the regulatory tools, while the provinces are responsible for designing, administering and funding their respective prescription drug subsidy plans. Alone, neither order of government is capable of addressing the financial sustainability problem or initiating thoroughgoing change in drug utilization patterns. Given the current stalemate, the time may have come to consider a more radical proposal in which one order of government assumes responsibility for prescription drug policy in Canada.

Prescription drugs: The real sustainability problem

13 Figure 2The debate concerning sustainability of a primarily publicly funded universal health care system has been raging in Canada since the late 1990s. In the early to mid-1990s, all provincial governments restrained spending in their efforts to end deficits. As the largest spending envelope in each province, health care was not spared (the provinces undertake roughly 90 per cent of public health care spending). In constant inflation-adjusted dollars, per capita public health spending declined over these years. After 1997, with their accounts balanced, governments began to loosen the fiscal purse strings and spend on health care again (see figure 2).

On the basis of the growth in overall public health spending since 1997, some commentators and governments have argued that medicare – defined as medically necessary hospital, diagnostic and physician services covered under the general principles of the Canada Health Act – is no longer fiscally sustainable. These arguments ignore the fact that private health care spending has been growing even faster than public spending. Indeed, over the period 1992–2004, the rate of growth of private per capita spending was double that of public spending.

13 Table 1Table 1 documents rates of growth of expenditure in various health sectors. From 1998 to 2004, spending on provincial and territorial public drug plans and private drug insurance plans has grown, on average, by more than 12 per cent annually in nominal terms. This is double the rates of growth in the entire economy and in core medicare hospital and physician services.3 Medicare expenditures are sustainable; what may not be sustainable are rates of growth in non-medicare sectors, drugs in particular. Perhaps governments focus on medicare spending because they feel they have some ability to control expenditures of their publicly administered and financed single-payer systems. In contrast, prescription drugs inhabit a multipayer world of mixed public/private funding and administration.

The federal government runs its own public drug plan for Inuit and registered First Nations individuals. This is the fastest growing component of the Non-Insured Health Benefits (NIHB) programs administered by the First Nations and Inuit Health branch of Health Canada. Currently, that growth rate matches the growth rate of the provincial and territorial drug plans.

What does all this mean? The growth in public and private drug plan expenditures greatly exceeds the rate of growth in medicare expenditures – despite generous wage, salary and fee schedule gains by health providers in recent years. Moreover, while the growth of medicare expenditures remains very much in line with the growth of the Canadian economy, the growth of prescription drug plan costs soars well above this rate. Growing at an annual average of over 20 per cent – almost four times the growth rate of the economy and medicare – the Quebec drug plan is in a league of its own in terms of both budget growth and program design. Implemented in 1997, the Quebec plan is in fact a public-private social insurance scheme rather than the tax-funded plans found in Quebec before that date, and in the other provinces today.4

Extrapolation of these trends leads to the conclusion that provincial and territorial governments are caught on the horns of a dilemma. They can continue to earmark an ever-growing share of their health budgets for their drug plans and try to improve their existing single-payer medicare systems with less money. Or they can increase copayments and reduce drug plan benefits (and beneficiaries) so that they can earmark more money for core medicare services.

The recent decision by the Supreme Court of Canada in Chaoulli v. Quebec (Attorney General) has raised the possibility that provinces will have to permit parallel private insurance for core medicare services unless they significantly shorten waiting lists for medically necessary elective surgeries (see “Two-tier health care and the Supreme Court,” p. 10, and “Law and politics,” p. 24). Chaoulli may have loaded the dice against any significant pharmacare initiative and in favour of judge-decreed priorities. Investing more public money in medicare at the expense of public investment in prescription drugs may be the path of least resistance, but it will mean offloading costs to private individuals and private insurance plans – and may actually raise total health care costs. Managers of private plans can be expected to pass on cost increases by use of larger copayments and higher premiums. For sure, the Supreme Court has hampered the ability of the provinces to make strategic health care decisions. In these circumstances, it is probably wise for the provinces and territories to transfer their public drug plan responsibilities to the federal government and for Ottawa to accept that, for the first time, it must assume administrative responsibility for delivering a major “slice” of public health care in Canada.

Federal pharmacare: Putting the pieces together

13 Figure 3Before describing a federal pharmacare program, it is worth reviewing the existing pieces of the $19 billion prescription drug expenditure pie in Canada shown in figure 3. The size and nature of each piece could change depending on the design of any new pharmacare program – with the devil in the details.

The largest slice is the almost $8 billion spent (in 2004) by the provinces and territories (including Quebec) on their public drug plans. Between 1970 and 1986, every province introduced a prescription drug plan. Most were drug subsidy programs aimed at seniors and individuals receiving social assistance, two high-risk groups generally without access to private health insurance (which most often comes in the form of employment-based group plans). In the 1990s, provincial governments limited benefits and hiked copayments and other user fees associated with their drug plans, often hurting the poorest and most vulnerable. For example, Saskatchewan, faced with a severe debt crisis in the early 1990s, turned its universal plan into a targeted program; Quebec revamped its tax-funded plan into a public-private social insurance program. Almost all provinces shifted costs from the public purse to private pockets. Their experience with these short-term cost-saving measures followed a consistent pattern: drug plan costs originally declined only to surge upwards again within a year of the changes.

In contrast to single-payer medicare programs, there is considerable variation in the administration, delivery and benefits of provincial and territorial drug plans. In addition, each jurisdiction has its own drug formulary, and makes its own final decision concerning what pharmaceutical products it will list on the basis of clinical efficacy and, to a more limited extent, cost effectiveness. Recently, in another cost-saving effort, all provinces except Quebec have agreed to a Common Drug Approval assessment conducted by an intergovernmental body, the Canadian Coordinating Office of Health Technology Assessment (CCOHTA). While CCOHTA now provides assessments on the clinical and cost effectiveness of new drugs, the actual decision whether to include any new drug in its formulary, and the extent to which the assessment shapes the final decision, remains in the hands of individual provinces and territories.

A further provincial expenditure of $1.4 billion takes place on medicare-covered prescription drugs. Since these drugs are dispensed within hospitals and are considered medically necessary, there is no “patient participation” in paying for them. Individuals who are Inuit or registered First Nations receive $327 million in drug benefits not covered under the provincial and territorial plans. Finally, provincial and territorial workers’ compensation plans cover $97 million worth of drug benefits. All of these public plans supplement or complement $6 billion of private health insurance, most of which is in the form of employment-based benefit plans.

There is also the critical regulatory role played by the federal government. On the basis of clinical evidence of a given drug’s safety, efficacy and quality, Health Canada’s Therapeutics Products Directorate decides whether any new prescription drug can be marketed in the country. A quasijudicial, arm’s-length federal tribunal, the Patent Medicine Prices Review Board, regulates the retail prices of new patented prescription drugs. Currently, generic drug prices are not regulated because neither level of government has clear constitutional jurisdiction. Ottawa’s authority to regulate the prices of patented prescription drugs comes from the explicit mention of patents as being under federal jurisdiction in the Constitution, but this authority does not extend to generic drugs. Nor do the provinces have any obvious constitutional foothold that would allow them to regulate generic drug prices.

Federal pharmacare would ensure that one level of government would be responsible for the regulatory functions as well as administering, delivering and funding a single national drug plan. With the simple administrative agreement of the provinces (if this is even necessary), price regulation could be extended beyond patented drugs to generic drugs, something desperately needed for a country whose generic prices are among the highest in the world.

13 sidebarRegulatory power over prescription drug prices may be necessary but is not the ideal means to control the cost of a major pharmacare program. Many OECD countries with national drug plans negotiate discount prices from pharmaceutical companies on large-scale orders. The bargaining leverage exercised by national drug plans arises from the size of the market at stake and the power to include or exclude drugs from the national formulary. Discount prices negotiated between drug manufacturers and government are common practice in Australia, New Zealand and many western European countries (see sidebar on Australia’s Pharmaceutical Benefit Scheme). They are also common practice among the larger Health Maintenance Organizations in the United States. But not in Canada: with few exceptions, governments in Canada do not purchase prescription drugs in bulk. Instead, they rely on user fees and formularies to control costs. With a national pharmacare plan, Ottawa could undertake such bulk purchasing at discounted prices.

The advantages of federal pharmacare

From the perspective of improving the workings of Canadian federalism, a pharmacare scheme operated by Ottawa presents several clear advantages over the status quo. First, this realignment would clarify roles and responsibilities in an area of health care where they have been ambiguous. While the provinces currently pay for almost all public drug coverage in Canada, they lack the regulatory powers of the federal government. Federal pharmacare would ensure that the order of government with the constitutional powers of regulation would also administer and pay for public prescription drug coverage.

Second, federal pharmacare would address the provincial claim of a vertical fiscal imbalance, the claim that Ottawa has rapidly increasing tax sources and the provinces have rapidly increasing spending responsibilities that are endangering the fiscal health of all but the most prosperous. A federal pharmacare program would be of particular benefit to “have not” provinces that can least afford such a large rapidly growing program.

13 sidebar 2While Ottawa vehemently denies the existence of a structural fiscal imbalance, the premiers may have seized the momentum in this debate by establishing an independent Advisory Panel on Fiscal Imbalance through their Council of the Federation. Due in March 2006, the panel’s report is likely to provide a strong rationale for the transfer of further fiscal resources (or “tax room”) to the provinces, thereby putting significant political pressure on the federal government. Federal politicians have little incentive to transfer tax room given past experience with the Established Programs Financing (EPF) deal of 1976–77. At the time, Ottawa lowered its taxes to give tax room so the provinces could raise theirs. Ever since, Ottawa has reminded Canadians of this major rejigging of the tax system by calculating transfers to the provinces as the sum of cash plus so-called “tax transfers.” Thirty years on, the provinces offer no recognition of the fiscal benefits they received from this deal.

Federal pharmacare would be a proactive and constructive way of addressing the fiscal imbalance argument without repeating the EPF. Potentially, this is a “win-win” solution. The provinces would obtain significant ongoing fiscal relief while Ottawa would deliver a service that directly touches most Canadians and would be able to influence, very directly, the sustainability of public health care.

The advantages of federal pharmacare to Canadians should be obvious. The current patchwork of provincial, territorial and federal drug programs has created, in the words of one researcher, a “dog’s breakfast” of benefits and exclusions that vary across the country.5 In particular, there exists a major east-west cleavage: drug coverage programs are considerably thinner in the four Atlantic provinces than programs offered in all the jurisdictions west of those provinces. To the extent that federal pharmacare can both eliminate the disparities of public drug coverage across the country and level up to one of the more generous provincial programs, it will act as a national unifier.

Costs and other downsides

The single largest impediment to federal pharmacare is the program cost. In fact, the potential cost of a pharmacare program has perennially deterred the federal government from proceeding with a cost-shared provincial-territorial program for prescription drugs in the traditional medicare mould.

The annual operating cost of a federal-only pharmacare program could range from a low of $8 billion to a high of $19 billion, depending on the public program’s relationship to private prescription drug insurance, the level of copayments and other user fees, and changes in prescription and utilization patterns in response to the new system of public coverage. The lower figure of $8 billion is the current cost of all provincial and territorial drug programs and assumes that the federal program would not disturb any of the other pieces in the prescription drug pie and would be about midway or less in its program benefits. The higher figure of $19 billion is the total prescription drug pie and presumes that federal prescription drug insurance replaces all other public and private plans in the country as well as all out-of-pocket costs in the form of the insurance copayments and deductibles paid by individual Canadians. Using 2001 data, a recent consultant’s study arrived at a figure of $13.6 billion for universal, first-dollar-coverage (no copayments, deductibles or other user fees) federal pharmacare. After inclusion of drug price inflation since 2001, this amount is very close to the higher figure of $19 billion.6

Unless federal pharmacare “levels up” coverage and accessibility to the most generous provincial program today, some groups will see no advantage in the reform. To take an obvious example: if Ontario residents, who already have one of the more generous programs in the country, end up receiving fewer benefits while paying the same taxes, they will be understandably dissatisfied. By the same token, if federal pharmacare means levelling up to a more generous national drug plan, it should be possible to eliminate current federal NIHB drug benefits and the differential benefits and expenditures associated with it and the questionable distinctions it makes among Canadians – including the distinction between registered and nonregistered Indians.

One scenario is a universal program with copayments in line with one of the more generous provincial plans but one nonetheless designed to minimize the displacement of current private insurance arrangements. From the beginning, it would make sense to include the $1.4 billion cost of hospital-based prescription drugs in federal pharmacare. If that were not done, provincial and territorial governments would have a built-in incentive to cost-shift from inpatient to outpatient prescription drug therapy. A very rough “back-of-the-envelope” calculation would put the cost of this type of federal pharmacare at $12 billion.

How would the federal government pay for this, given that we may no longer be able to count on the level of budget surpluses (a total of just over $60 billion) of the last eight years?7 There are two possibilities. Since the federal government will be taking responsibility for the riskiest portion of the health care portfolio – and assuming the provinces’ in-hospital expenditures on drugs – it seems reasonable that $6 billion, or half the cost, should take the form of a reduction in the Canada Health Transfer, one of Ottawa’s major transfers to the provinces. This is a substantial reduction, but leaves sufficient financial leverage for the federal government to enforce the Canada Health Act. The other $6 billion should come from a potential rollback of current federal programs or transfers that are clearly in areas of provincial jurisdiction or – if the federal cabinet prefers – a modest tax increase.

What would we get for this money? A truly universal program in which Canadians receive medically necessary drug therapies on the same terms and conditions wherever they live in the country, whatever their history and risk profile and whether they are inside or outside a hospital. These conditions of access could be spelled out in a new Federal Pharmacare Act that would parallel the Canada Health Act.

Beyond money, we would need to avoid a federal pharmacare program operated in isolation from provincial health reforms. As it is, provincial drug plans, administered in a silo separate from other health services, are generally disconnected from the provincial health reform agenda. Moving pharmacare to a different level of government could exacerbate this problem by creating even more separation between prescription drug policy and health reform. To counteract this tendency, it will be essential for the two orders of government to have a meeting of minds as to how prescription drug therapy fits in the larger health reform agenda.

Those interested in primary care reform, in particular, need to address prescription and drug utilization patterns and behaviours as part of a larger effort to improve diagnosis and monitor ongoing treatment. With federal pharmacare, Ottawa would still depend on the provinces and regional health authorities to influence drug prescribing and utilization. While costs would be the federal government’s primary concern, the provinces’ primary focus should be on the overall health impact of prescription drug therapies. To avoid strategies that focus on cost-shifting, the two orders of government would benefit from a common reform strategy that simultaneously aimed at improving health outcomes and containing health costs.

Taking the broad view, federal pharmacare should be one element in a larger strategy of transforming and sustaining public health care in Canada. After hospitals, prescription drug therapies now constitute the largest sector of health care expenditures. Indeed, we now spend $3 billion more on prescription drugs than we do on all physician care (see figure 1). We now have a prescription drug therapy for virtually every illness or injury. Paradoxically, there is little evidence that this huge expenditure is leading to better health.8 This raises the question of whether Canadian-style medicare systematically overweights the value of prescription drug therapy relative to alternatives.

Pharmacare would give the federal government a powerful incentive to fund an independent research institute capable of systematically and regularly testing prescription drug therapies against promising nondrug therapies. Public research that is not funded or compromised by the pharmaceutical companies is essential to determining whether there are superior alternatives to prescription drug therapies to treat certain conditions. If it were responsible for administering and funding pharmacare, the federal government would have a strong incentive to examine more effective and lower-cost alternatives to prescription drug therapies. For example, there is clinical evidence indicating that nondrug cognitive behaviour therapy (CBT) administered by psychologists can be at least as effective as antidepressant medication in treating severely depressed outpatients.9

Quebec: A separate but equal solution

In September 2004, one province stood outside the premiers’ consensus in asking the federal government to take over responsibility for prescription drug care. Quebec Premier Jean Charest gave few reasons for his objections, but they can easily be inferred. On one level, his opposition simply reflected his province’s historic opposition to federal involvement in all areas of social policy. On another level, Charest was protecting a provincial policy environment which has been supportive of the research-and-development-based pharmaceutical industry, almost half of which is located in Quebec.

The simple solution would be to proceed without Quebec’s collaboration. This could take two forms. The first would be to impose a federal pharmacare program on Quebec. It is difficult to see how this could be done. Although the federal government has a strong constitutional foothold in this particular policy domain, it does not have sole jurisdiction. Moreover, any Quebec government would resist – strenuously – any unilateral initiative as an invasion by Ottawa of Quebec’s jurisdiction over social policy.

The second, more plausible approach is simply to build a federal pharmacare program around the existing Quebec drug plan. While some might trumpet – or decry – this as asymmetrical federalism, the more important criticism is that such an approach could undermine the objectives of federal pharmacare. It would create an enormous policy doughnut in which program benefits varied enormously inside and outside Quebec. It would reduce Ottawa’s negotiating leverage with a pharmaceutical industry either based in Quebec or threatening to move its manufacturing capacity from other parts of Canada to Quebec – or offshore. Finally, given two disparate health and industrial policy regimes, it would put Quebec and Ottawa on a major collision course, and generate new intergovernmental conflicts over prescription drug regulation, health policy and industrial development.

The best approach is neither of the above. Instead, we need to negotiate a compromise between Quebec and the rest of Canada. A precedent is the Canada Pension Plan/Quebec Pension Plan in which two programs, with very similar (but not identical) objectives and administrative design, are implemented simultaneously. This solution would require the Quebec government to deal with the potential wrath of some pharmaceutical companies for replacing its industry-friendly policies with a more health-oriented prescription drug program and policy environment. It would also require a resolute federal government, willing to pick up the tab only on the explicit agreement that Quebec fundamentally redesign its current drug program and that the other provinces, in turn, accept the CPP/QPP arrangement. The quid pro quo would be clear. For replacing its current program – likely unsustainable in any event – Quebec would retain control and receive an annual federal transfer for a Quebec drug plan that would be portable (and interchangeable) with the federal plan.

A constructive response

During the past decades, we have seen continual intergovernmental squabbling over public health care, federal transfers, fiscal imbalance and equalization. These disagreements have produced very little in the way of improved programs and policies for Canadians. Federal pharmacare offers not only a constructive response to evidence of a growing fiscal imbalance between the provinces and the federal government but also a project whereby Ottawa could enhance national unity by “touching Canadians directly.” More than this, given its existing regulatory powers, the federal government is the only level of government able to contain, effectively, the cost of a public prescription drug plan in the long term. Whether it would have the political will to use its power to exact concessions from the pharmaceutical industry remains an open question, but federal pharmacare would provide the capacity.

Federal pharmacare would, overnight, give each of the provinces the fiscal breathing room within its health budget to increase its investment in medicare, home care, long-term care, mental health and public health, where necessary, as well to focus more heavily on the “upstream” determinants of health. With prescription drug plans removed from the equation, the annual growth of public health care costs in the provinces would diminish significantly, reducing or eliminating the crowding-out effect that health care budgets have had on other public budgets during the last few years. As for Quebec, federal pharmacare could help the provincial government curtail an unsustainable program that is already seen as providing limited coverage for seniors and the poor because of its high user fees.

Continue reading “Federal Pharmacare”