This is Part 2 of a three-part series on pharmacare in Ontario. Click here to read Part 1.
I don’t recall the exact date, but it would have been in early 2018. My daughter had been to the doctor and gotten a routine prescription. I dropped her off at home and then went to the local pharmacy to get the prescription filled. As I wandered the aisles, waiting the standard 10 to 15 minutes, I realized with a start that I’d forgotten my insurance-benefits card at home. Sighing at my own forgetfulness, I began to wonder whether the pharmacist would have my insurance information on file. If not, I figured, I’d pay out of pocket and file the receipt later. No big deal.
It wasn’t any deal at all, it turns out: I had been worrying about nothing. When I picked up the medication and pulled out my credit card, the pharmacist shook her head. “It’s covered,” she said. “The new OHIP rules.”
Oh, yeah, I thought. That was dumb of me.
On January 1 of that year, my daughter, along with 4 million other Ontarians, had come under what the Liberal government had branded “OHIP+.” The program meant that OHIP-insured Ontarians under the age of 25 no longer had to pay for prescriptions — more than 4,000 different medications were covered. OHIP+ was universal and mandatory. I couldn’t have paid if I’d wanted to.
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It was also controversial from the start. That’s why I felt so silly for having forgotten. I’d been covering the rollout of OHIP+ since it had been announced the previous April. Eric Hoskins, then Ontario’s minister of health and long-term care, had made the announcement, stating that the program, which cost roughly $500 million a year, represented “a major step toward universal pharmacare.” But critics of the government attacked the program. So did some of the people who stood to benefit from it — my wife and I included. As a local journalist with an interest in Ontario political news, I’d been covering the controversy, too. Somehow, though, it had slipped my mind.
To be clear, although there were critics of the plan, OHIP+ wasn’t a political flop. A poll by Campaign Research in early January 2018, published just as the program was rolling out, found that 72 per cent of respondents approved of the idea; only 18 per cent were opposed. It also found that the plan was a potential vote-mover, one that seemed likely to benefit the Liberals. But the poll probably gave an overly optimistic view of the Liberals’ situation. Even people who saw value in the idea of making sure that every young Ontarian had drug coverage could quibble with how the government had gone about implementing it.
The objections, in general, went something like this: Why would the government insist that every young Ontarian have their drugs paid for entirely by the province when many of them were covered, at least in part, by private drug plans? Why was there no means testing that could make sure scarce taxpayer dollars would be diverted to those families that needed the financial help? Was this the best use of available resources?
Recall the story I started with. The day I went to the pharmacist, my wife and I were both employed. Our family had drug coverage through a policy into which my then-employer had enrolled me automatically. Our household income, which the government knows and records via tax filings, was, by any metric, healthy. But the new law forbade me from paying for my daughter’s medication out of pocket. It also prevented my workplace benefits — which I paid for every month through an automatic salary deduction — from covering the cost. It struck me as perverse that a fellow Ontarian making less money than I was and having no benefits plan would have to contribute to my daughter’s care.
Absolutely, there were Ontarians who benefitted from OHIP+. When the program went into effect, a government press release, citing stats from the Conference Board of Canada, noted that OHIP+ would mean “an estimated 1.2 million people in Ontario without drug coverage” would now receive common medications “completely free of charge.” But here’s the thing: that very same press release noted that more than 4 million people were now automatically enrolled. That’s a lot more than 1.2 million.
The front-line pharmacists of this province were the people responsible for managing the rollout of OHIP+. They’re also the people most attuned to the struggles of Ontarians who can’t pay for their prescription medications and sometimes have to go without. In an interview with TVO.org, Allan Malek, the executive vice-president of and chief pharmacy officer for the Ontario Pharmacists Association, said that he and his organization were glad the Liberals had put forward something like OHIP+ for discussion. “They threw a rock in the pond and made some ripples,” he noted approvingly. “This is a conversation we needed to have.”
“I’m a glass-half-full kind of guy,” Malek added. “That’s true of my organization, as well. OHIP+ was good news for a lot of people. But we wouldn’t have structured it the way that the government did.”
I stopped Malek there and related to him the anecdote I shared above. I told him of my frustration with knowing that I’d benefitted from a system I didn’t really need and that the money spent on my family could have been put to better use helping Ontarians who truly needed it. Malek agreed: “We were subsidizing people who didn’t need a subsidy. The children of Ontario were generally very well-covered.” Malek noted that an annex to Hoskins’s own just-released national-pharmacare report includes a breakdown of spending on pharmacare by province — and Ontario’s numbers stood out.
Indeed. In 2017, the year before OHIP+ went into effect, 40 per cent of the cost of prescription medications purchased in Ontario was covered by various private benefits plans, and 48 per cent was covered by the provincial government through a variety of existing programs — meaning that only 12 per cent was paid out of pocket by individual Ontarians. And even that number, Malek warned, was likely an exaggeration of the scale of the problem: some unknowable percentage of that small minority would have been reimbursed by private drug plans after a receipt had been submitted to an insurer. Ontario’s level of out-of-pocket spending, as a percentage of the provincial total, was the lowest of any province in the country, well under the national average of 17 per cent. Its share of public payment was tied for second-highest.
These numbers are for all Ontarians, not just those under 25. But they offer a look at what the status quo was on the day before OHIP+ came into force. The system wasn’t broken, Malek says. It could have been improved, easily, and at a relatively modest cost. But that’s not what the government chose to do. I asked him why, and, after a thoughtful pause, he said, “My gut tells me it was an ideological preference … it made fiscal sense to go another route while still getting the same end result.”
We’ll return to that notion later. For now, consider another issue that Malek flagged: there’s an obvious political appeal to helping children. It’s hard to argue against it. But kids are generally healthy. It’s the blessing of youth. Tragedies happen, of course; youth does not confer immunity from sickness or injury. But the demographic that can be expected to have the best overall health, the fewest chronic medical conditions, and relatively little need for subsidized medication is precisely the demographic that the government decided to cover with a universal, mandatory pharmacare program.
In fairness to the Liberals, insuring those under 25 was just the start of their plan. In March 2018, a few months after the first phase of OHIP+ was implemented and three months before the provincial election, the Liberals announced that they would expand the program to cover those 65 and older. This would have brought an additional 2.4 million Ontarians into the fold, at a cost of close to $600 million a year. That’s about $100 million more to cover 1.6 million fewer people — but, as Malek noted, the young consume less medication than the old. The plan would save the average senior, the government said, $240 a year.
Of course, that never happened. Before too long, OHIP+ would be totally changed. But for that story, we’ll have to wait for Part 3.