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Low-income adults who do not have employer-sponsored dental coverage through a publicly funded program - and most don't - must pay for their own dental care. Because the cost is often prohibitive, too many adults avoid seeking treatment at dental offices. Instead, they turn to family doctors and emergency departments for antibiotics and painkillers, which cannot address the true cause of the problem. In 2012, in Ontario alone, there were almost 58,000 visits to Ontario hospital emergency rooms due to oral health problems. Why is access to dental care essential now?

A person's oral health will affect their overall health. Dental disease can cause pain and infection. Gum disease has been linked to respiratory infections, cardiovascular disease, diabetes, poor nutrition, and low birth weight babies. Poor oral health can also impact learning abilities, employability, school and work attendance and performance, self-esteem, and social relationships. It is estimated that 4.15 million working days are lost annually in Canada due to dental visits or dental sick days. Persons with visible dental problems may be less likely to find employment in jobs that require face-to-face contact with the public.

Why is there such a difference in coverage? In short, dental care and pharmacare were not included within the original scope of Canada's national system of health insurance (medicare), and despite repeated evidence of the need to correct this oversight, is still not covered today. Instead, we are left with a patchwork of private employer-based benefits coverage, limited publicly funded programs, and significant out-of-pocket payments for many. Publicly funded dental programs for children and youth do exist for low-income families, including the dependents of those on social assistance. Most provinces and territories have some access to drug coverage, mostly for seniors and social assistance recipients, and there is some support for situations where drug costs are extremely high.

Pharmaceutical coverage in Canada remains an unco-ordinated and incomplete patchwork of private and public plans - one that leaves many Canadians with no prescription drug coverage at all. This has many negative consequences including: Three million Canadians cannot afford to take their prescriptions as written. This leads to worse health outcomes and increased costs elsewhere in the health-care system.

One in six hospitalizations in Canada could be prevented through improved regulation and better guidelines. Medicines are commonly underused, overused, and misused in Canada. Two million Canadians incur more than $1,000 a year in out-of-pocket expenses for prescription drugs. The uncontrolled cost of medicines is also a growing burden on businesses and unions that finance private drug plans for approximately 60 per cent of Canadian workers. Canada pays more than any comparable health-care system for prescription drugs. We spend an estimated $1 billion on duplicate administration of multiple private drug plans. Depending on estimates, we also spend between $4 billion and $10 billion more on prescription drugs than comparable countries with national prescription drug coverage plans.

Affordable access to safe and appropriate prescription medicines is so critical to health that the World Health Organization has declared governments should be obligated to ensure such access for all. Unfortunately, Canada is the only developed country with a universal health care system that does not include universal coverage of prescription drugs. From its very outset, Canada's universal, public health insurance system - medicare - was supposed to include universal public coverage of prescription drugs. The reasoning was simple. It is essential to deliver on the core principles of "access," "appropriateness," "equity" and "efficiency." Building universal prescription drug coverage into Canada's universal health-care system, based on the above principles, is both achievable and financially sustainable.

A public body - with federal, provincial and territorial representation - would establish the national formulary for medicines to be covered. This body would negotiate drug pricing and supply contracts for brand-name and generic drugs. Importantly, it would use the combined purchasing power of the program to ensure all Canadians receive the best possible drug prices and thereby coverage of the widest possible range of treatments. To patients, the program would be a natural extension of medicare: when a provider prescribes a covered drug, the patient would have access without financial barriers.

To society, universal access to safe and appropriately prescribed drugs and access to dental care will improve population health and reduce demands elsewhere in the health system. The single-payer system will also result in substantially lower medicine costs for Canada. In short, Canada can no longer afford not to have a national pharmacare program and a national dental care program. Disclaimer: The Guelph and Wellington Task Force for Poverty Elimination is a non-partisan organization. However, the poverty task force does have ties with two Guelph federal party candidates. Andrew Seagram, the NDP candidate, is a current member of the task force and Lloyd Longfield, the Liberal candidate, is a past member.

It is not wrong for cities to care for their employees. But leaving these costs to the cities makes about as much sense as requiring every homeowner to maintain the roads and infrastructure surrounding their properties. Just as would happen if infrastructure were left to individual homeowners, the system that leaves drug coverage to individual patients and employers - including cities - creates an unco-ordinated patchwork. Most cities provide coverage, but some can't afford to. Some workers qualify for coverage, but some don't.

The same pattern plays out in cities, hospitals, schools and businesses across the country. As a result, millions of Canadians are without drug coverage and one in 10 Canadians cannot afford to fill their prescriptions. This patchwork is inequitable and profoundly inefficient because it fails to place responsibility for drug coverage and costs with the right level of government.

Provinces and the federal government are responsible for Canada's health-care system. They are best suited to manage access to medicines as an integral part of health care for all Canadians. They are also best positioned to reduce waste and overspending on pharmaceuticals. Having multiple drug plans operating in every province - including multiple private plans for public-sector employees - needlessly duplicates administrative costs. This fragmentation also diminishes Canadians' purchasing power on the global market for pharmaceuticals. Provincial governments wield about $10 billion in purchasing power when negotiating rebates for prescription drugs. This reduces public drug-plan costs by millions of dollars, but it does not lower costs for cities and other organizations that insure their workers through private drug plans that are minuscule in comparison. No matter how hard they try, cities would have about as much chance of negotiating competitive drug prices as homeowners would have of securing the best prices for infrastructure planning, engineering and construction.

Some things are best done through well-planned, population-level procurement processes. A recent study in the Canadian Medical Association Journal shows how a universal public drug plan run by the provinces could provide all Canadians coverage for prescription drugs while saving taxpayers $7 billion per year. Such a program would end the downloading of prescription drug costs to local governments and thereby allow cities to better address problems like traffic, housing and crime.

The federal and provincial governments should take responsibility for our prescription drug problem by implementing universal pharmacare for all Canadians. Doing so would support the health and wellbeing of public-and private-sector workers alike at far lower cost than Canadians are paying for our disorganized, patchwork system today. Steve Morgan is a health policy professor at the school of population and public health at the University of B.C.

Prescription drug spending in Canada's private sector has increased nearly fivefold in 20 years, from $3.6 billion in 1993 to $15.9 billion in 2013 [3x[3]Express Script Canada. 2013 Drug trend report. ESI, Mississauga; 2014 (http://www.express-scripts.ca/sites/default/files/uploads/FINAL_executive%20summary_FINAL.pdf [accessed 01.06.14])See all References][3].

Private drug plans in Canada are often considered wasteful because they accept paying for higher priced drugs that do not improve health outcomes for users and use costly sub-optimal dispensing intervals for maintenance medications. As a consequence, it is estimated that private drug plans in Canada wasted $5.1 billion in 2012, which is money spent without receiving therapeutic benefits in return [4x[4]Express Scripts Canada. Poor patient decisions waste up to $5.1 billion annually, according to express script Canada. (June)Press release, ; 2013 (http://www.express-scripts.ca/about/canadian-press/poor-patient-decisions-waste-51-billion-annually-according-express-scripts [accessed 01.06.14])See all References][4]. This amount represented 52% of the total expenditures of $9.8 billion by private insurers on prescription drugs for that year [5x[5]Canadian Institute for Health Information. Drug Expenditure in Canada 1985 to 2012. CIHI, Ottawa; 2013See all References][5].

Respondents from all categories mentioned that, in contrast to employers, the over-riding objective of unions is to maximize their benefits with minimal co-payments for their employees.

The study focused on large unionized workplaces that had Administrative Services Only (ASO) plans, where the employer is responsible for the costs of benefit plans and bears the risks associated with it, while insurers are just hired to manage claims.

This study focused on ASO arrangements because they are the most common insurance option chosen by large private-sector firms [16x[16]Sanofi. Sanofi Canada healthcare survey. Rogers Publishing, Laval; 2012See all References][16]. Those organizations whose activities resided solely in the province of Québec, where the regulation of private drug plans differs [17x[17]Commissaire de la santé et du bien être du, Québec., Les médicaments d’ordonnance: État de la situation au Québec. Gouvernement du Québec, Québec; 2014See all References][17], were excluded.

Respondents from all categories indicated that consistency of benefits with other market players is of significance to employers.

Sean O’BradyxSean O’BradySearch for articles by this authorAffiliationsÉcole de relations industrielles, Université de Montréal, Montreal, Quebec, CanadaInteruniversity Research Centre on Globalization and Work (CRIMT), Montreal, Quebec, Canada, Marc-André GagnonxMarc-André GagnonSearch for articles by this authorAffiliationsSchool of Public Policy and Administration, Carleton University, Ottawa, Ontario, CanadaCorrespondenceCorresponding author at: School of Public Policy and Administration, Carleton University (RB 5224), 1125 Colonel By Drive, Ottawa, Ontario, Canada K1S 5B6. Tel.: +1 613 520 2600.xMarc-André GagnonSearch for articles by this authorAffiliationsSchool of Public Policy and Administration, Carleton University, Ottawa, Ontario, CanadaCorrespondenceCorresponding author at: School of Public Policy and Administration, Carleton University (RB 5224), 1125 Colonel By Drive, Ottawa, Ontario, Canada K1S 5B6. Tel.: +1 613 520 2600., Alan Cassels

The employers indicated that their over-riding strategy is to maintain cost-neutrality in providing drug benefits – in the context of overall compensation – to employees: any increases in the costs of a particular benefits area must be off-set by cost-savings elsewhere. Controlling knowledge was also frequently reported by the union-side respondents (and by one consultant that services employers) as a strategy to achieve greater control over negotiations and plan design by firms. According to one union representative, “

the employer always has the advantage in this stuff because they have all of the information with respect to the reports and the costs from the insurer or the advisor”

According to one consultant, “no one knows the cost of drug benefit plans.” This respondent was arguing that few involved in benefit design, either in private firms, unions, or insurers, are sufficiently competent to undertake proper analyses of claims data so they do not really know how proposed plan changes could affect them. This lack of expertise has ramifications for the education of stakeholders on the outcomes of benefit design.

However, when speaking of for-profit insurers, participants from all groups argued that insurers have no financial incentives to cut costs for employers, as indicated by one employer saying: “from my experience on the committees, I don’t get the impression that the insurers are there to save costs for the employers. I haven’t seen it. It's always been the other direction.” This claim was also corroborated by a benefits consultant, who argued that “there has been a fair bit of inertia, you know, amongst the providers out there in actually doing something too radical, too leading edge” because “there's no direct financial incentive for insurance companies or pharmacy benefit managers to actually help employers save money”.

Expanding on this, another consultant argued that an insurer's commission structure, which is based on volumes of claims expressed in a dollar value, may in fact discourage insurance companies from proposing plan designs that reduce the volumes of claims, as doing so would adversely affect company profits. Furthermore, another benefits consultant indicated that insurers are experts who calculate risk and thereby have no aptitude for the creation of formularies. According to this respondent, the impact is that insurance companies excel at managing risk, yet fare poorly in designing cost-effective plans that rely on the design and implementation of formularies.

An interesting finding from the interview data was that respondents from all interviewed groups declared being in favor of introducing some sort of arrangement for a national drug plan. Some favored having a universal pharmacare program which would apply to all drugs, while others favored programs tailored for catastrophic drug coverage. Two of the insurers that responded to this question explicitly favored some form of universal catastrophic drug coverage while the other favored universal pharmacare.

Each of the union representatives and one employer interviewed for this study expressed their support for universal pharmacare. Three out of five consultants argued in favor of a national pharmacare plan while the other two favored some other form of national risk pooling or formulary management to address costs.

While a majority of interviewees favored some form of universal coverage, a few respondents from the insurer and employer sides expressed concerns that universal pharmacare is not feasible.

Finally, employers were most concerned with the government's role in distributing the costs associated with drug coverage among public and private players in the system. In fact, each employer expressed concern over this. Three of the four employers expressed concern over the government's role as a plan sponsor and how governments shift costs to the private sector. As described by one employer, “the government is a very big consumer of drugs” and if the drug companies “start losing money on the government side, they pass it on to private insurance”. Thus, government regulations that help employers contain costs are desired.

Marc-Andre Gagnon has received research funding by the Canadian Federation of Nurses’ Unions for a different research project related to drug coverage in Canada. Alan Cassels is co-director of DECA (Drug Evaluation Consulting and Analysis). The authors would like to acknowledge the financial contribution of the Canadian Health Coalition in order to pay for the transcription of interviews.

1. Bans insurance companies from dropping women when they get sick or become pregnant

2. Bans insurance companies from requiring women to obtain a pre-authorization or referral for access to ob-gyn care3. Improves the care of millions of older women with chronic conditions4. For women in new private plans, provides free coverage of mammograms and colonoscopies, one or more of which 20 million women have already received5. Beginning this summer, provides that free coverage will also include additional, comprehensive women's preventive services, including contraception in new plans6. Bans insurance companies from denying coverage for "pre-existing conditions," beginning in 2014. Currently, many women are denied coverage or charged more for such "pre-existing conditions" as breast or cervical cancer, pregnancy, having had a C-section, or having been a victim of domestic violence7. Ends the common practice of "gender rating," charging women substantially higher premiums than men for the same coverage, beginning in 20148. Provides greater access to affordable health coverage for women, with the establishment of new Health Insurance Exchanges for the millions who do not have health insurance through an employer, beginning in 2014. Currently, less than half of America's women can obtain affordable insurance through a job

After all is said and done, it appears that the relentless war on the Affordable Care Act by those who call it socialism has actually been, in large part, a war on women

In their recent CMAJ article, Morgan and colleagues present just such a study.2 Using recently available national data on drug use and costs, they report an economic model that estimates the cost of implementing national public drug coverage. The model anticipates several key evidence-based consequences of universal pharmacare. Patients who were previously unable to access drugs would now receive them, which would drive up costs. However, the greatly enhanced purchasing power of a single national third-party payer would be expected to confer an ability to negotiate substantial reductions in the prices of many drugs, as other countries have experienced and as Canadian provinces are already trying to achieve through collaboration. The model also assumes that patients would incur modest copayments, as is the case in other countries with universal pharmacare.

The bottom line? The best estimate would require the federal government to spend an extra $1 billion per year. That’s a lot of money, but considering that federal transfers for health care to the provinces and territories amount to $35 billion — not to mention everything the federal government spends directly on health — relatively speaking, it’s not that much of an increase. As with all modelling studies, these estimates rely on assumptions, and the associated uncertainties mean that costs could be higher — as much as $5.4 billion per year in the worst imaginable case. Equally, though, national pharmacare could well result in net savings for government — perhaps as much as $2.9 billion per year.

Morgan SG, Law M, Daw JR, et al. Estimated cost of universal public coverage of prescription drugs in Canada. CMAJ 2015;187:491–7. Abstract/FREE Full Text

A small number of drug classes are key drivers of overall costs and would continue to be so with or without pharmacare. Some (e.g., biologic agents) represent classes in which many emerging new therapies are expected to arise. Thus, the $1 billion estimate might not be stable going forward. But knowing this information may now enable policy-makers to develop specific interventions focused on reducing the impact of these key cost drivers even further.

Although the Canada Health Act has long enshrined the value of equitable, public health care coverage for all Canadians, its enactment by governments to date has been hypocritical in the absence of pharmacare. Canada has the dubious distinction of being the only country with universal health care coverage, but not universal pharmacare. As we have said before,3 the time to end this hypocrisy is long overdue; all of our peer nations have already done so. The moral case for universal pharmacare has always been apparent. With a strong economic case for pharmacare also evident, there can be no more excuses for delay. In this election year, it is especially timely for Canadians to demand that their next government enact national pharmacare.

Tang KL, Ghali WA, Manns BJ. Addressing cost-related barriers to prescription drug use in Canada. CMAJ 2014;186:276–80. FREE Full Text

Even more striking are the potential benefits to the private sector: no matter what, it would save a lot of money from pharmacare. Currently, nearly half of all drug expenditures in Canada are incurred by the private sector, divided almost evenly between individuals, whose costs would drop by more than half under pharmacare, and private drug plans, whose current costs for nearly all prescription drugs would disappear completely. Of note, a big chunk of public savings would arise from what governments presently spend on private drug coverage, such as for civil servants. With projected savings like these, one would expect that private companies, governments and individuals alike should be clamouring for pharmacare.

tanbrook MB, Hébert PC, Coutts J, et al. Can Canada get on with national pharmacare already? CMAJ 2011;183:E1275. FREE Full Text

Today, the program is partially dismantled. Half of the provinces have scaled back their seniors' drug benefits. The rest of the system looks shaky. There has been no nationwide analysis and very little public commentary, just snippets from individual provinces. Now a Montreal think-tank has pulled it all together. The Institute for Research on Public Policy has just released an informative study, "Are Income-Based Public Drug Programs Fit for an Aging Population?"

The institute commissioned three health-care specialists - two from the University of British Columbia and one from Harvard - to track the retrenchment, analyze its impact and offer advice to the provinces that haven't ratcheted back seniors' drug benefits. The authors acknowledge that financial pressures the provinces face are real. Canada's population is aging, drug expenditures are escalating and the economy is no longer robust enough to accommodate rising costs.

What they question is the wisdom of restricting access to medicine for the highest-needs segment of the population

Former B.C. premier Gordon Campbell was the first Canadian politician to curtail drug coverage for seniors. Shortly after taking power in 2001 he imposed a three-year budget freeze on his province's health ministry. The following year, he raised the co-payment on seniors' prescriptions to $25. In 2003, he implemented an income-tested plan - "Fair PharmaCare" - requiring better-off seniors to contribute up to 3 per cent of their annual income to the cost of their medications.

Over the next decade, four of his counterparts followed his lead, imposing restrictions on seniors' drug benefits. In 2012, former Ontario premier Dalton McGuinty went part-way. He reduced public drug coverage for seniors with incomes over $100,000. They are now required to pay the first $100 of their annual drug bill and a $6.11 co-payment (triple the standard seniors' fee of $2) for each prescription. In 2013, Alberta indicated it was considering the B.C. model. That is where things now stand.

The appeal of eliminating universal drug coverage is obvious. It reduces the burden on the public purse. It makes medicare more sustainable. It targets benefits to those who really need them. What's not to like? Three things, the authors say:

It is detrimental to the health of seniors. The more financial barriers governments put in front of elderly residents, the less likely they are to fill their prescriptions. Seniors in B.C. forgo drug treatment at twice the rate of their Ontario counterparts. Although they pay the highest price, taxpayers lose, too. Providing older people with medically necessary drugs is much cheaper than paying their hospital bills when their conditions become unmanageable.

It penalizes Canadians over 65 with chronic conditions or serious disabilities. "In effect the deductibles under income-based programs are tantamount to imposing a specific income tax on people with the highest medical needs," the authors say. This violates the spirit of medicare. And it is financially inefficient. By unloading the cost of medications on seniors and private insurers, governments reduce their leverage in the pharmaceutical marketplace. The fewer citizens they buy for, the less bargaining power they have.

There is a fourth drawback the authors don't mention. The premiers are pushing a full-fledged pharmacare plan out of reach, in defiance of the will of their citizens. Public opinion polls consistently show that 75 to 90 per cent of Canadians want medically necessary drugs brought into medicare. That was part of the vision forged by Saskatchewan premier Tommy Douglas and chief justice Emmett Hall, chair of the Royal Commission on Health Services half a century ago. They recommended that the cost of hospitalization be lifted from families' shoulders first; physicians' fees would be covered next; and finally prescription drugs would be publicly insured.

Today Canada is the only country in the developed world with a universal public health-care system that excludes coverage of prescription drugs. Policy-makers were inching in the right direction until the turn of the millennium. As of 2000, seniors, social assistance recipients and aboriginal people had full drug coverage.

Now the premiers are moving backward, creating an inequitable patchwork of drug coverage for seniors and lowering the likelihood of pharmacare for everyone else. The short-term savings may look appealing. The long-term costs will add up in ways Canadians haven't begun to contemplate.

Carol Goar'

WENDY MESLEY (HOST): It's funny, you know, we hear our health plan discussed in the United States and now you talk about our socialized medicine and it's sort of until you have a health problem, you assume everything is covered. But who falls through the cracks that you see, Samir? SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): Yeah, I mean, I treat a lot of older patients and those who are 65 and older generally are covered by a provincial drug plan. But, you know, I'm seeing more and more, especially after the recent recession, we have people who are closer to that age who lose their jobs and if they lose their jobs and they were relying on private drug coverage plans, they are not covered. And then they find themselves they can't afford their medications, they get sicker and they literally have to wait and be sick until they can actually get their medications.

WENDY MESLEY (HOST): What are you seeing, David? DAVID HENRY (PROFESSOR, DALLA LANA SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF TORONTO): I think this is right and it's a surprise to somebody from outside of Canada to find that in a country with a good comprehensive care system, there is not drug coverage. So patients with chronic disease, for instance diabetics, ironically in the city where insulin was discovered, are relying on free handouts from their physicians to provide what is really an essential medication; it's keeping them alive. WENDY MESLEY (HOST): Who do you think is falling through the cracks? What are you seeing?

CARA TANNENBAUM (GERIATRIC PHYSICIAN, PHARMACY CHAIR, UNIVERSITÉ DE MONTRÉAL): The vulnerable population in my mind are older adults with multiple medical conditions who are taking 5, 10, 15 medications at the same time and have to pay the deductible on that. And that adds up for a lot of them who don't have a lot of money to begin with, so they start making choices about will I take my drugs until the end of the month? Will I take every single medication that I have to? Do I really need those three medications for my high blood pressure, or can I let one go? And that could have effects on their health. WENDY MESLEY (HOST): Well, you mentioned diabetes, David. We heard earlier on "The National" this week from a woman in B.C. She has diabetes. That's a life-threatening disease if it's not looked after. This is what she said.

SASHA JANICH (PHON.) (DIABETES PATIENT): Roughly about 600 to 800 bucks a month. I don't get any help until I spend at last 3500 a year and then they'll kick in, you know, whatever portion they decide to cover. WENDY MESLEY (HOST): So, David, that's really common? People on diabetes aren't fully covered?

DAVID HENRY (PROFESSOR, DALLA LANA SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF TORONTO): Well, they're covered to a degree in B.C., but it's what we call the co- payment level that they have to make even under an insurance program. In Ontario, they don't have any insurance at all. They're going to pay the full market price if they don't have insurance through their employer, and they may lose that if they're out of work. WENDY MESLEY (HOST): What are you seeing? What's not covered? Give me an example. DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL):

Well, actually, one thing that I think is surprising to a lot of people is the variability in coverage among public drug plans in Canada. So something that's covered, even if you're covered under a public drug plan, for example if you have cancer and you have to take chemotherapy outside of the hospital, in many Canadian provinces that's taken care of. In Ontario, for example, it's not. And I think that many Canadians are surprised to discover, imagine the, you know, enormous stress of a cancer diagnosis, that on top of that you're going to have to pay out of pocket at least to very… sometimes to very, very high levels, in fact. WENDY MESLEY (HOST): Samir? SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): And even just the other day, I just was debating with a pharmacy about the cost of some vitamin D. I have a person who's under house, he's on social assistance, and they said: We'll give you a free blister pack, you know, so he can sort his meds. We'll give you this. And we were actually, you know, working out a pricing system so this guy could even afford something so that he wouldn't break bones and actually have a fracture down the road. So it's amazing how some of the basic things we think are important aren't even covered. WENDY MESLEY (HOST):

Well, we saw that the drug costs have almost doubled in the last 11, 12 years. Is part of the problem… there's only so much, it seems, money to go around for prescription drugs. Is part of the problem that there's too many… some drugs are too easily available while people who really need them are not getting them? And there's marketing playing into that. We see a lot of ads in the last ten years. Check this out. VOICE OF UNIDENTIFIED WOMAN (ANNOUNCER): (Advertisement) We know a place where tossing and turning have given way to sleeping, where sleepless nights yield to restful sleep. And Lunesta can help you get there.

UNIDENTIFIED MAN #1: (Advertisement) Anyone with high cholesterol may be at increased risk of heart attack. I stopped kidding myself. VOICE OF UNIDENTIFIED MAN #2 (ANNOUNCER): (Advertisement) Talk to your doctor about your risk. VOICE OF UNIDENTIFIED WOMAN (ANNOUNCER): (Advertisement) Ask your doctor if Lunesta is right for you.

DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): Well, I think it's probably not divided properly and I also think that we need to be very mindful of the ways in which advertising and marketing, whether it's direct to patients or consumers as we often consume from the American media on our television screens, or whether it's direct to physicians. So, you know, in fact, even in the U.S. under the Affordable Care Act, physicians are now required to declare any amount of money that they take from the pharmaceutical industry. We have no such sunshine law here in Canada. Don't Canadian patients want to know if your doctor has had their vacation or their last meal or their speakers' fees paid by the company that makes the drug they have just prescribed for you? WENDY MESLEY (HOST): Well, we saw in those ads they'll say: Ask your doctor. Is there a lot of pressure and is that contributing to the number of pills on the market? SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK):

Well, it's a huge amount of pressure, I think, you know, for… you know, if you're a doctor that relies on information or supports from pharmaceutical representatives, for example, then there is that pressure that you're put under, there is that influence that you have. But also, we know that if your patient asks you specifically and says, you know, what about this medication, you may say, well, it's easier to prescribe you that medication if that's what you really want. But there's actually five things you can do to improve your sleep and actually avoid being on that medication, but we don't get asked for that. WENDY MESLEY (HOST): But I want to be like the lady with the wings.

SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): And that's what I hear: Why can't I be like that? But I think it's important to think about the other options. WENDY MESLEY (HOST): David, what do you think? DAVID HENRY (PROFESSOR, DALLA LANA SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF TORONTO): I would like to focus a little bit on the prices that are being paid. We talked about usage and whether drug use is appropriate. There's also the price that is paid. Canada is paying too much. And if we can just return for a second or two to the idea of a national program, there's a huge advantage in being the sole purchaser on behalf of 35 million people, as it would be with a national program in Canada. And we know from experience you can reduce drug prices by 30, 40 percent. That's billions of dollars a year. WENDY MESLEY (HOST):

That's a political debate that you have launched and I hope that it gets taken up by the politicians. Who is buying these drugs? We have seen that there are more people having trouble getting drugs, more people using drugs. Who is it? DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): That are taking prescription drugs in Canada? WENDY MESLEY (HOST): Yeah. DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL):

Well, you know, interestingly over the last decade, we have seen an increase in prescription drug use in every single age category. So the answer is we all are. We're all taking more drugs than our equivalent people did a decade ago and I think… WENDY MESLEY (HOST): Teenagers? DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): Absolutely, teenagers and the elderly and everybody in between. And so the question really becomes: Are we any healthier as a result? You know, in some cases we're talking about truly life-saving treatment that are medical breakthroughs and, of course, we all want to see every Canadian have unfettered access to those important treatments. In other cases we may actually be talking about overdiagnosis, overprescription and as you say, Cara, sort of chemical coping of all different kinds. And I think that's what we need to kind of get at and try to tease out. WENDY MESLEY (HOST):

Well, and the largest group of all on prescription drugs right now, Cara, are the seniors. CARA TANNENBAUM (GERIATRIC PHYSICIAN, PHARMACY CHAIR, UNIVERSITÉ DE MONTRÉAL): The seniors, yes, and I'm very passionate about this topic because sometimes I see patients come into my office on 23 different drug classes, and that's when we don't talk about what drugs should we add but what drugs can we take away, and the concept of de-prescribing. And imagine if we could get people who are on unnecessary drugs, because as you get older you get added this drug and a second drug and this specialist gives you this and that specialist gives you that, but then there starts to be interactions between the different drugs that could cause side effects and hospitalization. And maybe it's time to start asking, well, what's the right drug for you at this time, at this age, with these medical conditions? And personalized medicine is something that we have been talking about. It would be nice if we could introduce that conversation into therapy and not just drug therapy, but all therapy. Maybe the drug isn't needed. Maybe physiotherapy is needed or a psychologist or better exercise or nutrition. So I think it's really a bigger question. WENDY MESLEY (HOST): Samir?

SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): Exactly. I mean, in my clinic the other day I had a patient who was on eight medications when she came with me, and… WENDY MESLEY (HOST): This is a senior? You deal with seniors as well. SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): Absolutely. And when she left my office, she was thrilled because she was only on two medications, mainly because some of the medications are prescribed to treat the side effects of other medications, for example, or the indications for those medications were no longer valid in her. But we added some vitamins and we just balanced things out appropriately. And she was thrilled because, as Cara was saying before, the co-pays, the other payments that one needs to pay for medications you don't want to take, that's a problem as well. WENDY MESLEY (HOST): We're going to take a short break, but we have one more discussion area which is: What are the next challenges that Canadians might face with prescription drugs? We'll be right back.

(Commercial break) WENDY MESLEY (HOST): Welcome back to our "National Checkup" panel. Danielle Martin, Samir Sinha, Cara Tannenbaum and David Henry are all here to talk about the next frontier. So we're hearing all of this exciting new science marches on and there's all of these new drugs, new treatments. Everyone wants them or everyone who needs them wants them, but they're expensive, right, Danielle? DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): They can be extremely expensive. So, you know, what we call these blockbuster drugs coming onto the market, some of them truly do represent breakthroughs in medical treatment and in some cases they can cost tens or hundreds of thousands of dollars a year. So they really are very expensive. But what I think many people may not realize is that the number of drugs coming out, even the expensive ones that are truly breakthroughs, is still a very small portion of the drugs coming out on the market. Many, many drugs that are being released and are expensive are marginally, if at all, really any better than their predecessor. So just because it's new and fancy and costs a lot doesn't necessarily mean that it's all that much better.

WENDY MESLEY (HOST): So what's going to happen, David? DAVID HENRY (PROFESSOR, DALLA LANA SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF TORONTO): We need to find a plan. These drugs may cost hundreds of thousands of dollars. Nobody can afford that individually. Tens of thousands, rich people can afford them but the average person cannot. So there's really no way we can cope with these unless we've got a plan and, in my view, it has to be a national plan. And the advantage of that are that when you're buying or you're subsidizing on behalf of 35 million people, you're going to get better prices and your insurance pool that covers these costs is much greater. So the country can afford drugs that individuals can't.

WENDY MESLEY (HOST): Samir, what do you see as the new frontier here? SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): I think the new frontier is going to be more personalized treatments in terms of how do we actually treat cancers, how do we treat certain rare conditions with more personalized treatments. WENDY MESLEY (HOST): Because it's very exciting, right? You have this cancer that's not that common and then you hear that there's a treatment for it and you want it. SAMIR SINHA (GERIATRICIAN, MOUNT SINAI/UNIVERSITY HEALTH NETWORK): And it has the possibility of alleviating a lot of suffering from unnecessary treatments that may not actually be… you know, be effective. But I think this is the challenge. If we want to be able to afford these, if we actually work together we're actually more able to afford them when we bulk-buy these medications. But the key is going to be that, you know, this is where the future is going and we're going to have to figure out a way to pay for them.

WENDY MESLEY (HOST): What are you looking forward to? CARA TANNENBAUM (GERIATRIC PHYSICIAN, PHARMACY CHAIR, UNIVERSITÉ DE MONTRÉAL): I'm really looking forward to seeing all these new treatments that we have spent decades researching. You know what the investment in health research has been in order to find new targets for drugs, in order to increase quality of live, in order to cure cancer, and then to send a message, oh, sorry, we're not going to give them to you or you can't afford to pay for them, then I think there is a lack of consistency in the messaging that we're giving to Canadians around equity for health care. So you could get your diagnosis and you could see a physician, but we way not be able to afford treating you. So I think this is something we need to think about it. It's very exciting, I think we live in exciting times, and looking at different funding strategies to make sure that people get the appropriate care that they need at the right time to improve their health is really what we're going to be looking forward to. WENDY MESLEY (HOST):

Tricky, though. It's a provincial jurisdiction, you've got to get all the provinces to agree to a list, and the list is getting longer. DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): Absolutely. I mean, I think actually one of the big myths out there about drug plans is that higher-quality plans are the ones that cover everything. And, in fact, that's not true. You know, we can use a national plan or a pan- Canadian plan or whatever you want to call it to target our prescribing and guide our prescribing in order to make it more appropriate, and that's another way that we're going to save money in the long run. WENDY MESLEY (HOST): Well, I learned a lot tonight. I hope our audience did too. Thanks so much for being with us. DANIELLE MARTIN (WOMEN'S COLLEGE HOSPITAL): Thank you.

Rather than moving toward a countrywide public monopoly, Canada's provinces should follow the lead of Quebec, which in 1997 implemented a reform that made drug insurance coverage in the province universal, but that relies on a range of insurers, public and private. The costs of the Quebec system have risen since its implementation, but this is largely because Quebec has resisted the temptation to ration access to innovative drugs. Indeed, among Canadian provinces, Quebec provides the most generous coverage by far. Whereas on average 23 per cent of all drugs approved by Health Canada between 2004 and 2012 were reimbursable by Canada's provincial public plans as of December 2013, the proportion in Quebec was 38 per cent.

A national plan, it is argued, would provide the public insurer with greater negotiating power, allowing it to obtain price concessions from pharmaceutical companies. But the savings would largely come from increased rationing rather than from greater efficiency. In the United Kingdom, there has been one policy after another since the 1990s aimed at controlling spending. Patients continue to suffer the consequences of a lack of access to many proven drugs. Likely as a result of such restrictions, despite screening rates that are among the highest in the world, English patients have lower survival rates for various cancers than most other industrialized countries. In New Zealand, another country frequently held up as a model, patients' access to innovative drugs is just as restricted, if not more so. Of all the drugs approved in the country from 2009 to 2014, barely 13 per cent were reimbursable by the public insurance plan, the worst result among 20 countries evaluated.

It is also important to note that while Quebec spends more on drugs, this goes hand in hand with lower overall costs in the public health care system compared to other provinces, as more accessible pharmaceutical therapies have likely replaced other kinds of more expensive medical care, like hospital surgeries. Quebec's mixed universal plan is not perfect, but it does provide coverage to all residents. And only 4.4 per cent of Quebecers say they had to forgo taking their medicines or skip a dose for financial reasons - less than the residents of all other Canadian provinces, and less than the residents of many other countries, too. If one is concerned with universal access to the latest drugs, that's a far better model to follow. Yanick Labrie is an economist at the Montreal Economic Institute (www.iedm.org)

However, according to a recent study in the Canadian Medical Association Journal, a universal public drug plan, one facilitated by the federal government and run by the provinces, would be cost-saving. Such a plan could provide coverage for all Canadians, ensuring access to the prescription drugs they need, while saving Canadians $7.3 billion a year - a 32 per cent reduction in total drug expenditures.

Individuals and businesses would save $8.2 billion while government expenditures would increase by $1 billion, which is considerably less than 1 per cent of current government expenditures on health care. The cost to governments could be even less because these figures don't account for the potential savings from reduced use of publicly-funded hospital and physician services resulting from improved access to safe, effective and appropriate medications. Let's stop for a minute and imagine: a social program that improves health and saves Canadians several times the added cost to the public purse. What's not to like?

A national pharmacare plan would yield substantial benefits for municipalities such as Hamilton. Approximately two-thirds of municipal employees in Canada, including those in Hamilton, receive supplemental health care insurance through their employer. In Hamilton, prescription drug coverage represents over half the cost of employee health benefits. Cities across Canada spend more than $500 million each year on drug plans. Imagine what it would mean to have that money available for other municipal priorities. Council's recent support of a national pharmacare plan clearly makes good economic sense. Hamilton has joined other cities across the country in its call for such a plan. Organizations and individuals are adding their voices through the Campaign for National Drug Coverage (www.campaign4nationaldrugcoverage). It's time to add prescription drugs to Canadian medicare. Dr. Brian Hutchison, Professor Emeritus of Family Medicine and Clinical Epidemiology and Biostatistics at McMaster University, is a retired family physician and is on the board of directors of Canadian Doctors for Medicare.

Consumer health advocates say they aren’t surprised that women’s claims for long-term-care insurance are higher than men’s.Because women typically live longer than men, they frequently act as caregivers when their husbands need long-term care, advocates say, thus reducing the need for nursing help that insurance might otherwise pay for. Once a woman needs care, however, there may be no one left to provide it.

“The Affordable Care Act recognized the gender bias in health insurance,” she said. “The same [rules] should apply to long-term-care insurance.”

A 2012 study by the National Women’s Law Center found that 92 percent of top-selling health plans in the individual market practiced sex-based pricing in states where the practice was allowed. (Fourteen states banned or limited the practice, according to the report.) Nearly a third of plans charged women at least 30 percent more than men for the same coverage, even plans that did not include maternity benefits, the study found.

Insurers that sell individual and small-group health policies on the state-based health insurance exchanges or outside them on the private market in 2014 will be able to vary premiums based only on geography, family size, age and tobacco use. (Plans that have grandfathered status under the law are exempt from these requirements.)

Under federal laws against sex discrimination in the workplace, employers are generally prohibited from charging women more than men for the same health insurance coverage.

Barely two months later, the Ungers were informed that when George turns 65 in May, his coverage will change and he will have a $10,000 lifetime benefit maximum.

Unger was a fire safety engineer. His employer's group insurance policy paid for his care when he went on long-term disability. Neither Unger nor his wife knew that when he turned 65, his coverage would change. Manulife didn't see fit to mention it on his first letter, issued when he was 64 years and seven months old.

Manulife Financial could not comment on Unger's case, but specified that long-term disability coverage typically terminates when an individual turns 65. "The employment status and the resulting eligibility for health benefits after age 65 is determined by the plan sponsor (employer)," wrote spokesperson Jana Miller.

If a patient is considered a palliative case, there's no limit to the care they can receive, said Barbara Busing, vice-president of clinical operations with the Niagara Region's Community Care Access Centre. "Most people want to be at home and we do everything we can to help them live out that aspiration," she said. Since a 2005 funding boost to end-of-life care, 6,000 more Ontarians are treated at home or in a hospice, said Health Minister Deb Matthews.

"Providing a loved one with the most appropriate, compassionate and comfortable care at the end of their lives is the right thing to do . . . and lifting the service maximums for CCAC delivered palliative care is part of that," she said in an emailed statement.

Four health associations representing Quebec doctors and medical students are demanding the province cover medical imaging done in private clinics.

“We propose (the government) invest this money in the public network to make it more productive so more tests are done with existing resources. Start by maximizing the use of equipment in hospitals, which are often limited due to chronic underfunding,” association president Frédéric Desjardins said in a statement.

Quebec Health Minister Réjean Hébert said he is open to extending coverage, in particular for ultrasounds.

insurance for drug costs is nothing like fire insurance. Population-based data from British Columbia and from Manitoba confirm that needs for high costs prescription drugs are seldom one-time events. People with the highest needs for prescription drugs require thousands of dollars’ worth of medicines, and they typically have such needs year-after-year, often until death.

Asking them to pay from 3% to 10% of their family incomes out-of-pocket before subsidies kick in is tantamount to putting a tax on illness.

A recent study found that one in ten Canadians don’t take their medicines as prescribed because of cost.

Data from Statistics Canada indicates that only half of Canadian workers have supplemental medical coverage that might cover prescription drugs – and only a third of Canadians who work for small businesses have such coverage.

Those who don’t have insurance through work can find it hard to buy insurance on their own.