Canadians have long viewed their single-payer health-care system with a near-religious reverence, largely because they assume that the United States will never adopt a similarly generous system. Games of compare-and-contrast determine Canada’s national virtues, and on health care the prevailing theory is that Americans are simply not as charitable and open-minded. In a 2017 editorial on Canadian Medicare superiority, for instance, the Globe and Mail dismissed the Affordable Care Act — popularly known as Obamacare — as a mere “baby-step toward universal health care.”

The problem with this sort of patriotic framing is that Canada’s health-care system is itself the culmination of many long-forgotten “baby-steps,” and would almost certainly never be created in its present form today. As seen in the United States during the lead-up to Obamacare, Canadian health-care policy debates are dictated more by the public’s preference for the familiar than any intangible qualities of national character. This is reflected in the caution and uncertainty surrounding the idea of a Canadian “Pharmacare” system, which was recommended by a recent report commissioned by Prime Minister Justin Trudeau.

When Obamacare was proposed in 2009, the vast majority of Americans were receiving health-care coverage through private insurance plans, mostly provided by their employers. Polls at the time suggested most Americans were broadly satisfied with the cost and quality of their existing coverage, leading to then-President Barack Obama’s infamous assurance that “if you like your health-care plan, you’ll be able to keep your health-care plan.” Then as now, the biggest public policy challenge in American health care was assuring the majority that they would not be forced to sacrifice their own quality of care for the benefit of the uninsured or underinsured.

Canada’s status quo with pharmaceuticals mirrors this situation closely. Canadian Medicare does not cover the costs of prescription or over-the-counter drugs, a reflection of just how old the system is. In the 1960s, when the Canadian health-care regime was first being devised, the majority of medical expenditures in Canada involved doctors or hospitals, so that was what the government agreed to cover. By the mid-1970s, the first decade under the modern Canadian health-care regime, doctors and hospitals still represented about 60 percent of total health-care expenditures. Today, however, dramatic advancements in medicinal chemistry have resulted in a Canadian medical culture that is far more drug-centric, with doctors and hospitals dwindling to less than 45 percent of the country’s medical spending.

Canada’s public health-care system has not kept up with this evolution in medical culture, but the private sector has. Today, about 60 percent of Canadians are enrolled in private drug insurance plans, mostly tied to their employers, similar to what the majority of Americans use for medical costs in general. And, like with Americans, polls suggest most Canadians feel their personal medical needs are sufficiently satisfied by this setup.

Thus, Canadian Pharmacare seems destined to run into the same obstacles Obamacare did.

If Ottawa assumed sole responsibility for providing prescription drugs for all Canadians, as the new report recommends, private drug insurance would inevitably decline. This would doubtless provide savings to employers but transfer a steep obligation to the federal government. To keep costs under control and prevent access abuse, Canada’s new state-run drug monopoly would need to implement bureaucratic systems to maximize efficiencies in product distribution. In other words, it would involve rationing, an inescapable byproduct when government becomes involved in the centrally planned distribution of limited goods.

The end result would be a significant number of Canadians unhappily pushed into a one-size-fits-all public plan offering more restricted access to a smaller pool of medicines than in their old private plan, in order to ensure an adequate supply of drugs are available to the 20 percent of Canadians the report estimates to have no insurance, or insurance that is deemed “inadequate.”

Is this a trade-off Canadians will be eager to make? What about the tax increases that will be necessary to finance the creation of a generous entitlement the report estimates will cost $15.3 billion annually by 2027? The report repeatedly evokes “Canadian values” in an effort to rally public support, but Canadians are not used to making material sacrifices to improve the health care of others. Indeed, the dirty system of Canadian Medicare’s popularity is the degree it panders to the selfishness of Canada’s comfortable middle class, who are taught to fantasize that they get access to hospitals and doctors for “free.”

The historian Robert Conquest quipped that “everyone is conservative about what he knows best.” Canadians endure rationing and infamously long wait times from hospitals and doctors because this is all they’ve known for 50 years. An alternative system offering any role for American-style private insurance in these realms seems, by contrast, frightening in its mysteriousness.

When it comes to prescription drug coverage, however, Canadians are deeply familiar with an American-style regime of overwhelmingly private coverage and can be expected to get defensive if the system of drug access they currently use is threatened. Fear of triggering a voter backlash of the sort that greeted the rollout of Obamacare will likely inspire the Trudeau government to pursue a far more modest, “fill the gaps” Pharmacare agenda than its ambitious report recommends.

National character, as usual, will play little role.

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