Flipping the script, Part 3: What can Canada learn from Ontario’s pharmacare experiment?

ANALYSIS: In less than a year and a half, the province went through multiple changes to OHIP+. Ontario’s experience offers a lesson to the rest of the country — but it may not be the one you think
By Matt Gurney - Published on June 21, 2019
Doug Ford and Christine Elliott
After the Tories took office in 2018, Health Minister Christine Elliott announced the Ford government’s intention to revise OHIP+. (Chris Young/CP)

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This is the final instalment in a three-part series on pharmacare in Ontario. To read Part 1, click here; to read Part 2, click here.

You’d think that offering people — children, no less — a break on the cost of medication would be a popular idea. For the Ontario Liberals, who, in early 2017, were facing grim poll numbers and the challenge of rising prescription-drug costs, it must have seemed so easy.

Kathleen Wynne’s government announced OHIP+ in April of that year. It took effect on January 1, 2018. Roughly 4 million Ontario residents under the age of 25 were automatically enrolled. The program covered the full cost of prescriptions for common medications — more than 4,000 were on the approved list. A poll conducted in the days after the launch of OHIP+ showed that it was popular, boasting a 72 per cent approval rating. In March 2018, the government announced that it would expand OHIP+ to include Ontarians 65 and older — another 2.4 million people. The total cost of the expanded program would have been slightly more than $1 billion a year.

But it never happened.

Less than seven months after OHIP+ rolled out, and barely three months after the expansion was announced, the Liberals were blown out of office in the 2018 provincial election. The Progressive Conservatives won a large majority, and Doug Ford replaced Wynne as premier. The day after Ford’s government was sworn in, OHIP+ changed.

“Today, our government is announcing our intent to fix the OHIP+ program by focussing benefits on those who do not have existing prescription drug benefits,” said Health Minister Christine Elliott in a statement. “Children and youth who are not covered by private benefits would continue to receive their eligible prescriptions free. Those who are covered by private plans would bill those plans first, with the government covering all remaining eligible costs of prescriptions. This new system would be more efficient, saving the taxpayers money and dedicating resources to the people who need it most. Even more importantly, it would continue to guarantee that children and youth still receive the prescription drugs they need.”

This was a major change. But it did not seem, at least at the time, to be a controversial one.

We’re now one year into the Ford government’s mandate, and the PCs have undeniably been battered in the polls. Just this week, there was a major cabinet shuffle, an obvious attempt to reset after a challenging first year. Ford’s personal popularity, in particular, has taken a beating; the premier has been booed at several recent public events. Against this backdrop, it’s difficult to assess how much of the damage, if any, can be traced to the OHIP+ changes.

They weren’t the subject of much comment at the time — perhaps because what was announced proved far more modest than what eventually happened.

Elliott’s original announcement essentially preserved the outcomes of OHIP+: Ontarians under 25 would not pay for their medications. The difference was that private insurers, who covered at least 40 per cent of all prescription-drug spending in 2017, would pay their maximum share first. OHIP+ would cover the balance. This represented a huge cost savings: Ontario would be only partially responsible for some costs instead of entirely responsible for all of them. In his 2018 fall economic update, then-finance minister Vic Fedeli said that the changes would save at least $250 million a year.

This was a defensible policy. Allen Malek, executive vice-president and chief pharmacist of the Ontario Pharmacists Association, told TVO.org in an interview that his organization supported such a model. The proposed revamp of OHIP+ still ensured that all young Ontarians would have access to needed medications, but it also kept as much of the financial burden as possible off of taxpayers’ backs. Public money would go to where it was most urgently needed.

But the transition — which came so soon after OHIP+ had been deployed and just it was hitting its stride — was jarring.

True, the Liberals’ program had experienced some early teething problems: Parents found the process disruptive, especially those whose children had pre-existing medical needs. Post-secondary students under 25 wondered why their automatic enrolment in drug plans continued when those plans were no longer usable. Routine pick-ups of medication refills slowed as pharmacists worked to enter information that the new process demanded. A parent might go to the pharmacy and discover that, because OHIP+ required slightly different information than what was already on file, their doctor and pharmacist had to communicate in order to work out how to get the prescription filled. Delays and frustration resulted.

Malek estimated that it took approximately three months for all the bugs in the OHIP+ process to be worked out. This, he said, was simply the learning curve for doctors, pharmacists, and parents. After that, the process settled down.

And then it was blown up again after the Tories won the election. OHIP+, in its original, fully universal form, lasted less than a year and a half.

There were more changes to come. The revamp, rolled out on April 1 of this year, was not what the Tories had committed to after taking office. Under the re-revised OHIP+, the province would pick up the total tab for anyone under 25 who had no private plan. That’s it. Anyone under 25 with a private plan would be left to their own devices — if that private plan didn’t cover 100 per cent of the cost, the balance would have to be paid out of pocket. (Families facing ruinously high prescription costs can still apply for help via the Trillium Drug Program, whether they’re privately insured or not.)

This reintroduced some of the same confusions that had existed during the early months of OHIP+’s first iteration. Once again, parents had to work with pharmacists and doctors to sort out what information was required to get their prescriptions. Parents with young kids suddenly needed to remember their insurance cards again and to pay out of pocket whatever balance was owing. There were again media reports of families harmed by the changes. The government promised to do better.

“We had spent a lot of time working with our members and with patients to adapt to OHIP+,” Malek told TVO.org. Just as they were getting used to it, he said, the government announced its changes. At first, he was optimistic — the original Tory proposal was what he thought the program should have been from the start. But then it was changed again, to the current model.

“The process [of the changes] was clunky,” he explained. “Patients would come in and say, ‘Wait, I thought the government paid for this?’ And our members would have to say, ‘No — well, they did, but now they don’t.’ Pharmacists, at the counter, were interpreting and explaining public policy to patients.” For many of those patients, there to pick up prescriptions for their sick children, the confusion and stress caused tempers to flare. Pharmacists bore the brunt of that. “They looked at us like we were villains,” Malek said. “People thought it was a scam, that we wanted their money.”

I put to him what I considered to be the critical question: The past two years have been a turbulent ride for Ontarians, but now, Eric Hoskins, the man who brought OHIP+ to Ontario before quitting provincial politics, says there should be a national version — universal and publicly funded. Ontario, in a very brief time, has experienced two totally different systems. What did the Ontario Pharmacists Association prefer? Or did it prefer something else entirely?

The Tories’ system is obviously cheaper, Malek said. It costs taxpayers less and leaves private insurance plans to do some of the heavy lifting. “We are blessed with a very high percentage of people who have drug coverage,” he noted. “But we don’t have 100 per cent. Many are struggling, and costs are going higher and higher as drugs get more sophisticated. There are gaps, and we have to close them. Individuals shouldn’t be left to choose between food and medication. Fundamentally, I think we all agree on that. But we can’t subsidize those that don’t need subsidies.”

Fair enough. But I had one more question for him: Did either system have any observable impact? Did the Liberal model result in a big change, for better or worse? Did the Progressive Conservative revisions change anything? Malek confessed that his organization had not seen significantly improved or worsened health outcomes in either case.

I put that same question to the Ontario Medical Association — did either model have an impact that could be measured? In an emailed statement, the OMA told TVO.org that the original Liberal model had been disruptive and burdensome. But there just hasn’t been time to see whether OHIP+ has made a difference to health outcomes.

In a strange way, that may be the only real lesson that Ontario can offer the rest of Canada as the federal government ponders national universal pharmacare: pick a plan and stick with it — if only to see whether it actually makes a difference in the end.

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