Pharmacare plan about who pays, not better health care

VICTORIA - It sometimes looks like Canadians' brains turn to mush when we start talking about health care.
Take the premiers' proposal that Ottawa create a national pharmacare program, taking over from the provinces. The premiers plucked the idea out of the air when they met to prepare for Paul Martin's televised health care summit next month. At this point, they don't know how it would work or what it would cost - estimates range from $7 billion to $12 billion.
A national plan actually makes good sense. It could help to ensure more efficient and effective drug purchasing and use. But that's not the premiers' focus. They looking at who pays, the provinces or the federal government.
And despite all the talk about sustainability, and controlling costs, and efficiency, that's mostly what we debate - who should pay.
Who cares? Pay taxes to Victoria for pharmacare, or pay taxes to Ottawa for pharmacare - that's hardly a critical health care reform question.
Even the debate about two-tier care or delisting services is about who pays. Allowing some people to pay extra for speedier or higher quality care doesn't reduce the amount we spend on health care by one cent. It just shuffles the cost around.
Right now, people pay taxes for the care we agree is needed. Under a two-tier system, taxes would be less and people would pay more out of their own pockets. Health care spending wouldn't change. (The U.S. has such a system, and health care costs actually consume a larger share of its GDP. If spending was at the same level in B.C., our health budget would be $2 billion higher.)
We're dancing around the problems, not dealing with them.
Take drug costs. They are one of the most rapidly increasing health care expenses. If we can find ways to control those costs - as B.C. has done with reference-based pricing, which ensures that the cheapest effective medication is used - then we'll have more to spend on other areas.
But we don't even really know if drug spending increases are a good or bad thing.
In B.C., prescription drug spending was $360 per person in 2003; the national average was $505. That could mean that we're doing a good job of controlling costs, or our doctors are more careful with prescriptions or simply that we're healthier - all good things.
Or it could mean that we're failing to make effective use of prescription drugs, and as a result more people are requiring surgery. We just don't know.
A national pharmacare plan that focused on effectiveness, not who pays, could help answer those questions. It could ensure that new drugs were only approved when they offered wide, cost-effective benefits. It could bargain effectively with big drug companies. And it would prevent drug companies playing provinces off against one another, winning approval for a new drug in one place and then supporting patients in other provinces pushing for the same thing.
The good news is that we have time to do this right. There is no health care sustainability crisis.
Yes, costs are rising rapidly and that should be a concern.
But despite all the doom-and-gloom, an internal federal finance department review released this year projected that health care spending would remain easily manageable until 2040 and beyond. Canadian health care spending as a percentage of GDP - the critical measure - was the same in 2001 as it was in 1991. There is no crisis.
The premier's pharmacare proposal isn't going anywhere. Prime Minister Paul Martin doesn't want the expense or the responsibility. His new interest is wait times. But shorter waits mean more money, and neither Martin nor most of the premiers want to spend more.
Maybe, under the bright television lights, the First Ministers will give up on arguing about who pays, and start talking about how we can deliver health care more effectively.
Footnote: One challenging in controlling drug costs is saying no. Drug companies regularly offer much more expensive new drugs with relatively small improvements in benefits for most patients. Governments that decide that it's not worth paying for each new drug can face intense pressure from patients, pressure groups and the pharmaceutical industry.