In an earlier posting, I mentioned research by Canada's Dennis Raphael, among others, on the difficulty of managing diabetes on a low income. The cost of a healthy diet is a major part of the problem; another is the cost of medications. In Ontario, prescription medications outside hospital are covered by public health insurance only for people over the age of 65 and for those on extremely low incomes. A new study by researchers at the University of Toronto (1) points out that this may be having a substantial impact on the health of people with diabetes.
We already knew that mortality among high-income Ontarians with diabetes has been declining faster than it has among those with low incomes, leading to a widening equity gap. Starting with a health records database including almost all Ontarians with diabetes and using median household incomes in the Statistics Canada dissemination area where they lived as a proxy for an individual's own income, the researchers found that the socioeconomic gradient for death, acute myocardial infarction (AMI) and stroke is substantially steeper among people under 65, who either pay out of pocket for their medications or rely on private insurance, than it is among those 65 and over whose prescription drugs are covered. "[A]s many as 5,000 deaths and nearly 2,700 AMIs or strokes could have been avoided among younger and middle-aged adults with diabetes if the gap between wealthier and poorer individuals had been identical to that seen among older groups. "
total number of people who died in Ontario motor vehicle accidents from 2002 through 2007, the years covered by the new study. If we could eliminate such accidents as a cause of death in this province, wouldn't we do it? And since the study looked only at the portion of the population with one disease, the overall toll of avoidable illness and death associated with lack of universal public insurance for prescription medications ("pharmacare") is almost certainly higher.To put that figure of 5,000 into perspective, that's the
Lack of pharmacare kills, in other words. Nothing is especially new about this realization. The new study cites previous research on the problem of drug costs for diabetics ... and it's now been more than a decade since a landmark study by Robyn Tamblyn and colleagues showed that emergency department visits and hospital admissions increased, and use of essential medications decreased, after Québec introduced co-payments in its public drug coverage for senior citizens.
Pharmacare is not just an equity issue; it's also an efficiency issue. The market power available to a single public purchaser could be important tool for cost containment. Indeed an important analysis published in the fall of 2010, which appears to have sunk without a trace, suggested that the lack of pharmacare is one of the reasons that prescription drug costs in Canada have been growing faster than in most other OECD countries, and argued that national pharmacare would reduce drug costs by 11.7 – 42.8 percent relative to current practice.
Failing to provide public insurance coverage for prescription drugs outside hospitals doesn't save money. It simply means that fewer costs are borne by the public treasury, and more by private insurers or people who may not be able to pay out-of-pocket, sometimes with fatal consequences.
At least under the current national government, there seems no hope for a federally initiated program. Ontario is one of the few provinces that are probably large enough to go it alone; a consortium of smaller provinces could do the same. Until that happens, the avoidable illnesses and deaths will continue, and we who are concerned with equity should laugh hollowly at all official claims that health policy is evidence-based.