Canada lacks a national pharmacare program, with drug costs borne by patients and a mix of private and publicly funded drug plans. Most insurance plans require copayments by patients, which can present a barrier to accessing needed drugs. Although provincial governments cover most or all drug costs for seniors and people on social assistance, the "working poor" do not have the same benefits, which can result in high rates of noncompliance and failure of patients to have their prescriptions filled.

"Patient-borne expenses for prescription drugs are an important issue and can have a negative impact on treatment access and outcomes," writes Dr. Braden Manns, University of Calgary, with coauthors. "Without better drug coverage systems, Canadians do not have universal health coverage."

Canada's patchwork system has many players who influence patient-related drug expenses, including federal and provincial-territorial governments, insurers and physicians. Physicians, for example, are often unaware of the difference in costs between two drugs with similar efficacy; they may prescribe a more expensive drug without recognizing the financial burden it may impose on a patient.

The authors recommend several solutions to these barriers including creating a national drug agency, changing the way Canada regulates patented drug prices, differential copayments for medications based on ability to pay or clinical value of a drug, and educating physicians on drug costs.

"A national drug agency would be well positioned to implement a universal drug program, where all Canadians would have access to some type of drug coverage," although the authors acknowledge barriers to a national plan.