Adding Our Voice to Pharmacare

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Adding Our Voice to Pharmacare

Through Cox Financial Group’s membership of the The Benefits Alliance Group we have been hard at work advocating for a better version of Pharmacare on behalf of Canadians.

Canada’s new—and only—national advocacy body for plan sponsors and plan members has earned a seat at the pharmacare table.

“Our voice is resonating,” says Carolyne Eagan, principal spokesperson for the Smart Health Benefits Coalition (SHBC) and President of Benefits Alliance, an SHBC member.

National pharmacare galvanized the creation of SHBC in the fall of 2023. “Political messaging around pharmacare was getting very concerning and the Benefits Alliance board of directors decided we had to gather the industry to create a common voice that could not be ignored,” recalls Eagan.

Five of Canada’s largest benefits advisory firms (Gallagher, GroupHEALTH, HUB, Navacord and People Corporation) joined Benefits Alliance as founding members of SHBC. Collectively, these organizations support health benefits plans for 65,000 small and mid-size employers, including more than 4,800 union benefits plans, which provide coverage for more than 10 million Canadians and their families. In April, the Conference for Advanced Life Underwriting (CALU), Canada’s professional association for leaders in the life insurance and advisory industry, became the seventh member organization.

SHBC’s membership and the hiring of a government relations firm, Bluesky Strategy Group, quickly opened doors to government offices, including Health Canada and the federal ministries for health, labour, seniors and families. SHBC is also meeting with individual Members of Parliament.

“They all say at first, ‘We haven’t had this voice before. This is interesting.’ They really like that we represent the day-in, day-out experience of business owners and plan members,” says Eagan. “We’re getting multiple requests for follow-up meetings with specific requests for agenda items, which is a very good sign.”

The latest on pharmacare

Most recently in late May, the House of Commons Standing Committee on Health, called HESA, invited SHBC to present as a witness during its review of Bill C-64, the proposed Pharmacare Act. Eagan presented two amendments to the Bill (see details below).

“This was a very big affirmation of our voice,” says Eagan. “SHBC is now formally part of the consultation process on the Bill.” 

Check SHBC’s website for updates on Bill C-64’s progress through the legislative process. As of early June, it was under review by the Senate.

A recent Benefits Alliance Voice podcast episode also provides more information, including pharmacare’s implications on access to new medications in Canada..

One concern that several presenters quickly brought before the HESA committee is the level of confusion around the interpretation of the Bill, notes Eagan. It proposes “universal, single-payer, first-dollar coverage” for a certain list of basic medications related to diabetes and contraceptives.

“We and many others interpret that to mean the government would pay for the medications on this list for all Canadians. As a result, insurance companies, on behalf of employer benefits plans and individual insurance policies, would not be permitted to pay, as outlined in the Canada Health Act,” says Eagan.

However, Health Minister Mark Holland has stated before HESA and publicly that Canadians would have choice. “For somebody who has existing coverage, you can continue to use that coverage. For somebody who doesn’t have coverage, or is under-insured, this would give them a path toward coverage,” Holland told the HESA committee.

“If choice is truly the intent of the Bill, it needs to be amended to reflect that,” says Eagan.

If it is a matter of choice, Canadians would need to use multiple systems depending on their personal use of medications. If they are using a contraceptive or diabetes medication on pharmacare’s list, they could, according to Holland, choose to claim it through the public system. Other medications—including contraceptives and diabetes drugs not on the pharmacare list—would be claimed through their employer or private plan, if available. 

Plan sponsors may also change their plan to eliminate coverage for all contraceptives and diabetes medications. “Employers may decide that what’s covered by pharmacare is enough and leave it to the public plan to serve as the single payor. Or they may incorrectly think the public plan would pay for all contraceptive and diabetes medications. The potential for confusion all around is high,” says Eagan.

In summary, moving to a single-payor public plan means Canadians could lose coverage for medications currently covered by a private plan. “A reduction in the number of drugs covered or a change in therapy may negatively impact health outcomes, leading to downstream public healthcare costs,” stresses Eagan.

It’s well documented that private plans cover new approved drugs more quickly than public plans, and they cover more drugs. The Canadian Health Policy Institute’s most recent edition of its “Public v Private Insurance Coverage of New Drugs in Canada” report, released in April 2024, found that private plans covered more than three times as many new drugs between 2018 and 2022, and coverage became available in less than half the time compared to public plans.

A different approach

SHBC proposed two amendments to the Bill before the HESA committee.

“First and foremost, without intervening in the core aims of the bill, we proposed an amendment that would provide for the Minister of Health to enter into secondary negotiations with provinces, in the event that a province were to formally reject the single-payor pharmacare,” says Eagan. “This should allow for Canada to negotiate and enter into an agreement with a province where universal, no-cost treatments are made available without the restriction of a ‘single-payor, first-dollar’ model.”

Second, SHBC proposed an amendment that would require public reporting and transparent communication of the results of the model implemented before any such program be expanded.

While all parties agree that Canadians who have no coverage or who cannot afford the out-of-pocket costs of their medications should have access to coverage through a public pharmacare program, this can be accomplished by building upon the current system.

“Let’s keep private and employer-paid plans, which work for the majority of Canadians today, in place. Let’s not spend money that duplicates what is already working today. The money saved would enable the public plan to do much more, including for high-cost and rare-disease drugs,” says Eagan.

SHBC is ready to help design a universal, mixed-payor pharmacare program that would be sustainable and affordable for the long term. “Other countries have done it, we can too,” says Eagan.

A starting point is to modernize the Canada Health Act to recognize advances in therapy.

Consider cancer drugs. The Act was originally written when cancer patients had to go to hospitals for treatment. However, decades later, cancer drugs now exist that can be taken outside the hospital. They are effective and have fewer side effects, but outside the Canada Health Act because they are taken outside of the hospital.

“That makes no sense. Essentially, a loophole in the Act has forced cancer patients to navigate public and private systems for coverage for a new and better standard of care,” says Eagan. “This can be hugely stressful for the patient and goes completely against the principles of the Health Act.”

Public plans in only two provinces so far—B.C. and Saskatchewan—have closed the loophole and pay for cancer drugs outside the hospital. Other provinces need to do the same, and that can be one objective of a multi-payor pharmacare. “Private drug plans have done their best to fill the gaps, but they were never intended to be the first payor in these instances where treatments have shifted from in-hospital to outside the hospital,” says Eagan.

“Private plans cannot be a surrogate for the Canada Health Act,” concludes Eagan. “Given today’s pipeline of drugs, we need a different strategy. That strategy needs everybody at the table: the federal government, the provinces, insurance companies, benefits advisors, plan sponsors and pharmaceutical companies. We are all part of the solution.”

This content is powered by the Benefits Alliance Group.

Bastack

Cox Financial Group is a proud member of the Benefits Alliance Group, which is Canada’s leading organization of independent benefits advisory firms. Collectively, we are responsible for more than $1.4 billion in annual benefit plan premiums and over $3.5 billion in retirement plan assets. Learn more at benefitsalliance.ca.

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