Significant public support for “pharmacare” over status quo, but concerns about costs remain.
A significant – and apparently increasing – number of Canadians are unable to afford the medications being prescribed to them, and they’re compensating by skipping doses, splitting pills, or simply not filling their prescriptions.
According to a wide-ranging new study by the Angus Reid Institute – in partnership with the Mindset Social Innovation Foundation – more than one-in-five (23%) Canadians report that they or someone in their household has taken one or more of these approaches to saving money on medication in the last 12 months. And over one-in-three say they have friends or family members who have financial difficulty paying for their prescriptions.
This new national survey also finds a strong public consensus on some fundamental value questions associated with the issue of prescription drug access and affordability — a large majority of Canadians share the view that “medicine should be part of medicare”.
Given this context, it should perhaps not come as a surprise that this new study finds widespread support for a national “pharmacare” system that would cover the cost of prescription drugs. There is decidedly less consensus on what the program should look like and – especially – how it should be funded.
- Many Canadians feel the pressure of prescription drug costs. More than one-in-five (23%) report that in the past 12 months they or someone in their household did not take their medicines as prescribed, if at all, because of the cost.
- Specifically, this includes: 14 per cent who report that they or someone in their household did not fill a prescription at all because of the cost; one-in-ten (10%) who did not renew a prescription; and one-in-seven (15%) who did things to make a prescription last longer, such as skip doses or split pills.
- Regionally, BC and Atlantic Canada show the highest levels of access problems (29% and 26% respectively).
- Though cost barriers affect Canadians of all ages and income levels to some degree, the young and the less affluent are more likely to report them, as are those whose medications are paid-for partially or mostly out-of-pocket.
- Many Canadians are also exposed to the issue in the form of vulnerability within their social network: 31 per cent of Canadians say they have friends or family members who cannot afford to pay for their prescription medicines and 36 per cent are close to people who have financial difficulty doing so.
- There are also strongly shared values underpinning Canadians’ orientation towards the issue of prescription drug access and affordability with very large majorities agreeing that “every Canadian — regardless of income — should have access to necessary prescription medicine” and that fundamentally “medicine should be part of medicare.”
- Most Canadians think this country’s current system of drug coverage has flaws. Almost seven-in-ten (69%) disagree with the statement: “overall the current system is working well enough and doesn’t need to be changed.”
- An overwhelming majority of Canadians (91%) express support for the concept of a national “pharmacare” program that would provide universal access to prescription drugs – and similarly large numbers support more detailed descriptions of such a plan.
- But there is a good deal of public concern on the cost side. Most of those surveyed indicated opposition to funding a national pharmacare program via a GST or income tax hike or through premiums, preferring to go with increased corporate taxes. Most Canadians (61%) also agree with the argument that “no matter what the research says, a national pharmacare plan will end up costing taxpayers lots of money.”
PART 1: Access to Prescriptions
Many Canadians cannot afford their prescribed meds
More than one-in-five (23%) Canadians report that, in the past 12 months, they or someone in their household did not take their medicines as prescribed, if at all, because of cost. Specifically:
- About one-in-seven (14%) reported that they or someone in their household did not fill a prescription at all;
- One-in-ten (10%) did not renew a prescription;
- And one-in-seven (15%) did things to make a prescription last longer (such as skip doses/split pills/etc.) due to cost.
A 2007 Statistics Canada Survey found one-in-ten Canadian individuals did not take their medicines as prescribed, if at all, because of cost. This Angus Reid Institute survey asked the same questions about use of medicines, but at the household level. While household figures would be expected to be larger, the 23 per cent figure in the current research suggests a widening of this problem over the intervening eight years.
These new survey results highlight access barriers in all provinces, with variations that may reflect public coverage policy.
- Consistent with prior studies, British Columbia has the highest rate of access barriers: 29 per cent failing to take medicines as prescribed, if at all. This is possibly because government in B.C. offers only “catastrophic” drug coverage and may also reflect the higher cost of living in this region.
- Atlantic Canada is also relatively high (26%).This too may be because of the limited nature of provincial drug plans in Atlantic Canada. The overall share of prescription drug costs paid for by government in New Brunswick (32%), Nova Scotia (37%), and Newfoundland and Labrador (37%) is lower than the national average (42%). (These figures are from CIHI and NHEX. Details can be found here.)
- Across the other major regions, reported cost-related non-adherence ranged from 19 per cent in Quebec and Manitoba to 24 per cent in Ontario.
Cost barriers affect all ages and income levels
All age groups experience some difficulty filling prescription drugs.
- Almost three in ten (28%) adults under age 45 do so. This level was reported even by the youngest group, aged 18 to 24 (27%). These people are less likely to be married with kids, so the statistic is more likely to reflect individual-level results. This group also has lower income and less drug coverage.
- Older Canadians are less likely to experience access barriers to prescribed medicines. But they still report them at relatively high rates compared to other comparable healthcare systems, as was previously found in the 2014 Commonwealth Fund International Health Policy Survey of Older Adults in 11 Countries.
Household income also makes a big difference in rates of non-adherence to prescriptions. Higher income Canadians are somewhat insulated from financial barriers to accessing medicines, though not completely.
- One-in-three (31%) Canadians with incomes under $50,000 reported they or someone in their household did not take their medicines as prescribed, if at all, because of cost.
- This figure was roughly half (16%) among Canadians with household incomes over $100,000.
Drug coverage is a big factor
The availability and extent of drug coverage is a strong predictor of access to prescribed medicines. (Survey findings regarding how many have drug coverage and who they are can be found in summary form near the end of this report.)
- Just one-in-ten (10%) survey respondents whose prescription drug costs are fully paid by insurance or government reported that they or someone in their household did not take their medicines as prescribed, if at all, because of cost.
- This figure doubles (to 20%) among those who have “most” of their drug costs paid by insurance/ government with some paid by themselves.
- And the figure nearly doubles again among other Canadians – those who have no drug coverage at all or coverage of up to half of their drug costs – with almost four-in-ten (38%) of these Canadians reporting that they or someone in their household did not take their medicines as prescribed, if at all, because of cost.
This is consistent with other research that shows that direct charges to patients can create barriers to filling prescriptions. For example, even among relatively well insured groups (such as employment groups in the USA or seniors in Canada), studies have shown that increasing co-payments for prescriptions reduces the use of medicines. (Many studies also show this results in higher cost elsewhere in the health care system.)
Out-of-pocket drug costs
What are Canadians spending on drugs out-of-pocket? These expenditures vary massively depending on health factors and, of course, on drug coverage. The ARI survey’s overall findings on this are broadly consistent with two 2007 surveys (Commonwealth Fund, CD Howe) (one of which showed Canadians are more likely to face high drug costs ($1,000 or more) than people in comparable countries).
The results from the ARI survey yield the following highlights on out-of-pocket drug spending:
- One-in-five (20%) Canadians spent $500 or more on prescriptions for their household in the past year, and a total of seven per cent paid $1,000 or more out-of-pocket.
- Insurance obviously makes a big difference in out-of-pocket expenditures, with less than one-in-ten people with such coverage paying $500 or more on prescriptions for their household.
- Perhaps surprisingly, Quebec had the highest rates of such burdens, with one-in-three households (32%) bearing such costs ($500+). This is despite the system of mandatory prescription drug insurance in Quebec. This is likely because Quebecers face monthly deductibles and co-insurance on drug purchases under the mandatory plan there. The limits on these charges are now over $1,000 per adult in a household in Quebec (after which the drug plan is supposed to cover all costs).
- Ontario had the lowest rates of these burdens. This likely stems from the relatively comprehensive coverage of seniors in Ontario, the universal “catastrophic” coverage for non-seniors (the “Trillium” program), and relatively good levels of work-related coverage.
- Not surprisingly, older Canadians were most likely to bear these burdens, one-in-five aged 55 to 64, and two-in-five aged 65+. The 65+ figure stems from somewhat limited coverage for seniors’ drug needs in provinces that offer age-irrelevant “catastrophic” coverage (like BC and MB) and in provinces that have limits on seniors’ entitlement to public coverage.
- Consistent with income-related access to insurance, high burdens are least common among Canadians who earn $100,000 or more – – but they are not insignificant given that about one-in-seven households with that level of income pay $500 or more for prescriptions they fill. One-in-five of their middle and lower income counterparts paid this much out-of-pocket last year.
Drug costs also a source of worry
The results of this new Angus Reid Institute survey also show pharmaceutical drug costs pose other burdens for Canadians in addition to prescription non-adherence.
- One-in-seven (15%) Canadians said, while they may not have missed taking prescribed medications, they did experience financial difficulty due to cost (such as needing to borrow or to cut back elsewhere).
- Almost one-in-four (24%) reported more broadly that they have worried in the past year about how they or their family might be able to afford the drugs they need.
- Asked to look ahead 10 years, almost half (46%) of the Canadians surveyed said they are very or somewhat worried about being able to afford drugs down the road.
Many know vulnerable people in their network
These issues of access and affordability affect Canadians indirectly as well in that many are exposed to the issue in the form of vulnerability within their social network. Specifically:
- One-in-three (31%) Canadians surveyed said they have friends or family members who cannot afford their prescription medications and have had to skip or delay renewing prescriptions as a result.
- And over one-in-three (36%) know of friends or family members who have financial difficulty paying for their prescription medicines.
This indirect awareness of people’s struggle with medication costs is in evidence across all main population groups, but most common in Atlantic Canada and in lower income groups.
PART 2: Canadians’ Values are Aligned
One of the objectives of this research was to explore the values underpinning prescription drug access in Canada — particularly, values associated with “fairness” and also with how medicines should fit with the traditional consensus on universal access to health care. The results will be encouraging to advocates of change in this area as they highlight strong shared values on these fundamental aspects. These values, in turn, are a central part of the overall context when Canadians consider possible policy proposals to address prescription drug access and affordability.
A matter of fairness
For the vast majority of Canadians, drug access and affordability are viewed as issues of fairness. For example:
- Almost nine-in-ten (88%) Canadians voice agreement with the statement: “Every Canadian — regardless of income — should have access to necessary prescription medicine”.
The same number (88%) agree that “It’s simply not right that some Canadians have to struggle to pay for the drugs they need”.
The survey results show a strong consensus on these values statements among Canadians from all walks of life. In both cases, a full majority indicate strong agreement, and overall agreement is shared by over four-in-five Canadians from all major population sub-groups.
Most believe medicines should be part of medicare
There is ongoing debate about whether the principles of universal healthcare should also apply to necessary drugs (along with dental and eye care, etc). This new survey’s broad attitudinal gauge also finds strong shared values on this count:
- Fully eighty-five percent of Canadians agree (40% strongly) with the statement: “It only makes sense that medicine should be part of medicare” and again this agreement is noted among Canadians from all walks of life.
PART 3: Prescription Drug Policy
This Angus Reid Institute/Mindset Social Innovation Foundation study is by no means the final word on Canadian public opinion on pharmaceutical affordability and its place in the nation’s health care policy — indeed, the research design was focused first and foremost on exploring the scale of the underlying problem of access barriers. That said, this study does serve as a useful initial temperature-taking on the concept of pharmacare in Canada.
Overall, on the policy side, the survey finds extremely high levels of support for the concept of a universal pharmacare program, though there is considerably less consensus among Canadians around the particulars of such a program and the cost of paying for it.
Most Canadians think status quo is flawed
This survey examined public opinion regarding the overall policy context surrounding this issue of prescription drug access and affordability – beginning with assessments of the status quo. The highlights here include the following:
- Fewer than one-in-three (31%) agreed with this positive characterization of the status quo: “overall the current system is working well enough” while two-in-three (69%) disagreed (22% strongly disagreed).
- This overall pattern of response is fairly consistent across the population — including with respect to levels of prescription use, insurance status, out of pocket costs, and experience or awareness of difficulties affording medicines.
- Regionally, Saskatchewan distinguishes itself with a far higher level of agreement that the current system is functioning well (at 46%, 10 and 20 points higher than any other region.) This might be because of the relatively high share of costs borne by government programs (provincial and federal for First Nations) in that province. Saskatchewan has the highest overall share of prescription drug costs paid for by government (51% versus the national average of 42%. Figures from CIHI, NHEX)
Reform a priority, but there are others
- Improving prescription drug access and affordability ranks as a priority for Canadians. Fully eight-in-ten (81%) of those surveyed described this as a high (45%) or very high (36%) priority issue for Canada.
- That said, most also feel that there are other priorities facing the health care system. Indeed, a separate line of questioning found 60 per cent agreement with the statement: “There are lots of other higher priority issues facing the health care system right now” (14% strongly agreed, 46% moderately) while 40 per cent disagreed.
A national pharmacare program
Fully nine-in-ten (91%) Canadians surveyed indicated overall support for “the concept of having “pharmacare” in Canada, providing universal access to prescription drugs” (51% voiced strong support).This support is essentially “across the board” – noted across provinces, age groups, sexes, education levels, and income levels. Indeed, broad support for the concept only goes as “low” as the high 80’s among federal Conservative party supporters.
This level of support for pharmacare remained high when at the end of the survey the policy option was described as “adding prescription drugs to the universal health coverage of ‘medicare’ so all Canadians have access to prescribed medicines without having to pay out of their own pocket.” In this case, almost nine-in-ten (87%) supported such a policy (39% strongly, 46% moderately). Again, this support was largely consistent “across the board” regionally, and by age groups, sexes, education levels, and income levels.
Overall support remains over the 80 per cent level among those who already have all of their drug costs covered by government or private insurance and among those who paid nothing for medicines in the past year, and stays over 90 per cent among those who did not receive any prescriptions last year.
Even many of those who oppose universal pharmacare say they would support other, less significant changes to the system. Those surveyed were asked to choose between two detailed opposing viewpoints, one in favour of a national pharmacare program and one opposed:
- Three-quarters (76%) opted for the positive.
- One-in-four (24%) took the negative.
The quarter who chose the latter option were asked whether they would prefer to keep the current system intact or would support some changes that stop short of a full pharmacare program. Roughly half (51%) of this group indicated they would support some changes, meaning that even a sizeable proportion of those opposed to pharmacare believe the current system could be improved.
Less consensus on specific elements of a pharmacare program
Notwithstanding the high levels of overall support for the concept of a universal drug program in Canada, this research also highlights a much lower degree of consensus in terms of what the specific elements of such a program might look like.
First of all, which level of government would be running such a program? Just over half (52%) of Canadians surveyed opted for “both the provinces and the federal government” – while the other half are evenly split as to whether it should be entirely or mostly the provinces (24%) or entirely or mostly the federal government (25%). A plurality or more of each major population group would opt for a federal-provincial combination, with significant minorities saying one or the other level of government should take the lead.
This survey also looked at Canadians’ views of two possible drug plan options, asking if each is perceived to be better or worse than the current system.
- With respect to a basic pharmacare program that only covers the full cost of the most common and essential drugs:
- Just over one-in-three Canadians (36%) thought this would be an improvement on the current system.
- 28 per cent thought this would be worse.
- The remaining 36 per cent chose neither.
- Canadians under age 45 and those with incomes over $100,000 were most likely to think such a plan would be an improvement (roughly four-in-ten in each case).
- What about a “co-pay” approach in which virtually all drugs are covered at a standard user-charge of $15 per prescription?
- Almost half of Canadians (45%) thought this would be an improvement over the status quo.
- 30 per cent thought this would be worse.
- Roughly one-quarter (25%) said neither.
Many Canadians are cautious about cost
Canadians are cautious that pharmacare will cost more than the status quo, and concerns on this count vary considerably across different constituencies.
- Two-in-five (40%) Canadians – including half (49%) of those with household incomes over $100,000 per year – believe that Canada “simply can’t afford universal drug coverage”
- And a sizeable majority (61%) agrees with the caution that “no matter what the research shows, a national pharmacare plan will end up costing taxpayers lots of money.”
Perhaps reflecting this belief, support for a variety of means of funding pharmacare is tepid at best, especially when compared to the very substantial majorities who support such a plan in concept:
Canadians’ preferred method for funding a national pharmacare program would be to restore the federal corporate income tax to its 2010 rate of 18 per cent. More than three-in-five (62%) indicated they would support a pharmacare system being brought in with this corporate-based funding source.
Other possible funding sources – such as increasing the GST or the basic income tax rate for incomes over $40,000 – get a “thumbs down”, with most Canadians surveyed indicating they would oppose a pharmacare system being brought in via these modes of funding.
Despite these cost concerns, eight-in-ten Canadians (80%) surveyed agreed that “it would be more efficient if there is one single system for drug coverage in Canada”.
Many Canadians worry that “having free prescription drugs will lead to abuse.” Half (51%) agreed with that statement – including nearly four-in-five Saskatchewan residents (79%) and two-thirds (66%) of past Conservative voters. Perhaps ironically, Canadians whose drug costs are mostly or entirely paid for by government or private insurance were slightly more likely to believe that having free prescription drugs will lead to abuse than Canadians who paid for most or all of their drug costs themselves.
PART 4: Additional Findings on Prescription Use and Coverage
This wide-ranging survey gathered additional data on Canadian households’ experience with prescription drugs. Some of these findings have been discussed earlier (for example, out-of-pocket drug spending), and some are briefly highlighted below.
Canadians use a lot of prescriptions; indeed, nearly nine-in-ten of those surveyed (89%) reported they or someone in their household had received a prescription in the past year. This is about the same as the number who visited a doctor’s office or clinic.
More than one-in-four Canadian households (27%) are very routine users of prescription drugs, reporting filling six or more prescriptions in the past year (about the same number as reported this many doctor visits).
This share of population receiving a prescription is far more than the number who received care in a hospital (29%), or received some kind of diagnostic test (61%).
Most Canadians have some drug coverage, but this coverage is incomplete for the almost three-in-ten (27%) Canadians who either pay for all of their drugs (11%), pay for most (10%) or have a roughly 50/50 plan (6%).
On the other hand, fully two-thirds (69%) of Canadians have most (54%) or all (15%) of their prescription costs paid for by government or an insurance plan. As discussed earlier, the extent of one’s drug coverage is highly related to the incidence of cost-related non-adherence to prescriptions.
There are some important differences in drug coverage across the population:
- British Columbians are most likely to have no drug coverage (19% versus the national average of 11%).
- Coverage differs by age group. Unsurprisingly, older Canadians have more comprehensive drug coverage: about three-in-four (74%) Canadians over age 55 have public or private coverage for half or more of their household drug costs. Younger Canadians have less coverage: just over half of Canadians under age 24 have most or all of their drug costs covered by government or an insurance plan.
Shachi Kurl, Senior Vice President: 604.908.1693 firstname.lastname@example.org
Image Credit – Charles Williams