British Columbia's PharmaCare Program: fair or foul?

and colleagues present a rigorous and comprehensive examination of pharmacare policy in British Columbia, specifically the introduction of co-payments for seniors in 2002, followed by an income-based " Fair PharmaCare " Program in 2003. Fair PharmaCare achieved its primary objective of reducing public expenditures on pharmaceuticals – an unsurprising accomplishment. Although politically hazardous, reducing pharmacare expenditures is technically straightforward; simply model co-payments and deductibles to achieve the budgetary target. The details of the plan, such as deductibles, co-payments and maximum contributions at different levels of family income, were designed to support other policy objectives, including a distribution of contributions and benefits more in line with ability to pay and improved access to medicines for low-income families. As Morgan and colleagues report, the first of these objectives was met. Although the second was not achieved, access was maintained – at least for two important and commonly used classes of medicine, antihypertensives and cholesterol-lowering agents (the only drugs examined). Does the program qualify as " fair " ? Several of Morgan and colleagues' findings raise questions about both the fairness and the adequacy of the program. First, average private payments for prescription drugs as a proportion of household income increased for low-income families (and at all other income levels) following the introduction of Fair PharmaCare. The financial burden of prescription drugs was heightened rather than alleviated. Second, average total public and private drug expenditures were positively related to household income for seniors and, except for households below the fourth per-centile of income, were unrelated to income among non-seniors (Hanley et al. 2006). Given the strong relationship between income and health, this suggests that access to drug treatment in British Columbia under Fair PharmaCare – and its predecessor programs – is based less on need than ability to pay. The implications of these findings for the poor and sick are clear. Given the co-payments required under Fair PharmaCare, households that include people with chronic health problems, especially low-income households, face large and increasing private costs of prescription drugs. Although private payments are limited by maximum contribution levels that vary from