Flipping the script, Part 1: How Ontario’s fight for universal pharmacare went national

ANALYSIS: Before Eric Hoskins took on pharmacare for Canada, he did so in Ontario. Here’s how this province conducted an accidental A:B test on universal drug coverage
By Matt Gurney - Published on June 19, 2019
Former Ontario Liberal MPP Eric Hoskins last week released his final report into national pharmacare. (Sean Kilpatrick/CP)

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This is Part 1 of a three-part series on pharmacare in Ontario. Look for Part 2 on Thursday.

In the early months of 2018, despite all the scandals and controversies that had shaken the Ontario Liberals over their nearly 15 years in power, it looked for a brief moment as if the Progressive Conservatives would find a way to snatch defeat from the jaws of victory.

PC leader Patrick Brown was well ahead in the polls and seemingly on course for an easy win in the June election. The numbers for the ruling Liberals and Premier Kathleen Wynne were bleak. It seemed like nothing could stop the inevitable Tory triumph.

Still, they gave it their best shot.

In January of last year, Brown held a press conference during which he denied allegations that he’d engaged in inappropriate sexual behaviour with young women. Despite initially pledging to stay on as leader, Brown lasted just a few hours: key advisers jumped ship, and Brown resigned the next day. The upper echelon of the PC leadership was wiped out. A leadership race was announced, and the party’s carefully crafted platform, “The People’s Guarantee,” was thrown into doubt. It was an astonishing period in Ontario history — so much so that you might have forgotten about something else that was happening around that time.

Last week, Eric Hoskins released his final report into national pharmacare, “A Prescription for Canada: Achieving Pharmacare for All.” Hoskins, a physician, led the panel of experts that produced the report, which succinctly notes in its preamble, “After hearing from many thousands of Canadians, we found a strongly held, shared belief that everyone in Canada should have access to prescription drugs based on their need and not their ability to pay, and delivered in a manner that is fair and sustainable. That’s why our council has recommended that Canada implement universal, single-payer, public pharmacare.”

Hoskins was chairing the federal panel for a reason: he’d already rolled out a version of that vision in Ontario.

On February 26, 2018, Hoskins, then Minister of Health and Long-Term Care with the Liberal government, resigned as both minister and MPP. The resignation came suddenly and took immediate effect. Hoskins was just the latest in a series of high-profile Ontario Liberals to announce that they were leaving politics. Deb Matthews, Liz Sandals, and Brad Duguid — all senior members of the party — had announced their intentions long in advance; instead of quitting immediately, they stated that they wouldn’t seek re-election but would serve out their terms. Hoskins simply up and quit. It was a grim sign for a party that ought to have been buoyed by the problems then rocking its primary rival.

But Hoskins wasn’t quitting politics to spend more time with his family. He went pretty much directly from his position at Queen’s Park to a new job — leading the very same panel that released its report last week.

Hoskins was a logical choice. During his time at Queen’s Park, he had overseen the rollout of “OHIP+,” a phased expansion of Ontario’s single-payer health program. Under OHIP+, announced in 2017 and effective January 1, 2018, any Ontarian under 25 with a valid OHIP card could have their prescriptions covered by the government — no need to pay a pharmacist or present a number for a private benefits plan. The pharmacy billed the government directly. There were plans to expand the program after the election to include seniors, too.

OHIP+ was a proudly universal program, similar to the one that Hoskins and his panel are now calling for nationwide. At an estimated cost of nearly $500 million a year, it was also a considerable investment. Cynics called it a pre-election bribe to voters. There was no means testing for ability to pay or household income level. Private insurance was instantly obsolete for those under 25 — and this was a feature, not a bug. “The Children and Youth Pharmacare program is the first universal drug program in Canada for youth 24 and under,” Hoskins said when OHIP+ was announced. It would provide “access to prescription drugs to over four million young people,” he continued. “By eliminating financial barriers to prescribed drugs, it will improve access, lead to healthier lives for our children and youth, and is a major step forward towards universal pharmacare.”

“Universal pharmacare” has long been a goal of some Canadians. Programs generally matching that description have been discussed for literally generations. In 2012, Steven G. Morgan and Jamie R. Daw wrote an article for Healthcare Policy in which they examined the history of pharmacare proposals in Canada. They found that one had been made as far back as the 1940s. Even as other developed countries — our liberal-democratic peers — embraced some form of universal pharmacare, Canada abstained.

This has created a gap in what is otherwise a fairly comprehensive, if flawed, system of universal health care: a doctor in a clinic or hospital will examine an insured patient at no upfront cost, provide necessary routine or life-saving medical care free of charge, keep the patient in a primary-care bed for as long as their condition requires, and then discharge them into a long-term-care ward or rehab hospital for treatment with no money down. Ontarians expect this; arguably, they take it for granted.

It’s not free health care, as such — far from it. Health care accounts for a massive and growing share of provincial spending. Still, access to care in Ontario doesn’t hinge on a patient’s wealth or chequing balance. It’s covered. But when a patient walks into their pharmacy to pick up the medications that the doctor who saved their life has prescribed, they’d better be able to pay up.

This was the problem that Hoskins and the Liberals sought to solve with OHIP+. And the problem is real: as many as 12 per cent of Ontarians may lack coverage for prescription drugs through public or private insurance (though that number is disputed — more on that later). Some public plans are already feeling intense strain. In early 2017, months before the Liberals announced the first phase of OHIP+, David Reevely, writing for the Ottawa Citizen, reported on problems facing the Trillium Drug Program, which covers Ontarians whose prescription costs are particularly high. Reevely noted that the cost of the program had been rising sharply — $1 billion over the previous decade — because ever more drugs, covering ever more diverse and rare conditions, were becoming available.

In 2017, the Canadian Institute for Health Information found that prescription drugs were the fastest-rising segment of health-care spending. Drugs were already the second-most costly expenditure in health care (behind hospital operations but ahead of physicians’ salaries), and prices were found to be increasing more than 4 per cent a year — roughly double the growth rate of hospital costs. Earlier reports, prepared for the Ontario government, had tracked the rising costs of drugs over decades and found annual increases of as much as 9 per cent. The problems of spiralling costs and unequal access to medications were obvious and logical priorities for the Liberals to address.

But OHIP+, much like the just-proposed federal model, was designed in a specific way: single-payer and totally universal. It mirrored our health-care system. This was controversial, and the program didn’t last long: the Ford government immediately made major changes to it after taking office last summer.

This means that Ontario has accidentally conducted an A:B experiment in pharmacare — just as Canada is considering a program of its own. So what did we learn? What worked well, and what could have been improved? What lessons can Ontario’s experience offer the federal government as it considers national pharmacare?

Stay tuned for Part 2.

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