In defence of free prescriptions

Expert opinion from University of Otago - Te Whare Wānanga o Otāgo

Opinion: The National party campaigned on the idea of bringing back prescription charges for those who could afford them. By this they mean people who don’t have a Community Services Card or a Gold Card.

The idea that people who can afford their medicines should contribute to the cost is appealing, and makes sense in theory. The problems only become apparent when you start to think of the practicalities.

There is a significant risk the people who need free prescriptions the most – people who are marginalised and poor – will miss out because they don’t have a Community Services Card.

People on a range of benefits and those living in Kāinga Ora housing are automatically provided a card, but there are many other people who would be eligible who will struggle to get a card.

Not many people finding filling in forms fun but for some people they are an insurmountable barrier: people who struggle with literacy (the online form is 11 pages) or dealing with bureaucracy; people who don’t trust the government and want to have as little to do with it as possible; and homeless people who have no address.

Our Free Meds study showed that when people on low incomes who have health problems can’t afford their medicines, they are more likely to end up in hospital.

Wherever the line for entitlement to free prescriptions is drawn, there will be people just over the line who are more deserving. National have decided that low income (CSC) and older age (Gold Card) are the appropriate criteria, but ill-health is not.

The system of assessing eligibility may be so costly to set up it outweighs the revenue recovered from reintroducing charges. It is likely that most of the administration will fall on pharmacists, so instead of focusing on patient care, these highly trained professionals will spend their time on bureaucracy

One of our participants in another study had type 1 diabetes and needed multiple prescriptions for insulin, test strips etc, as well as other regular medications. Other family members also needed many regular prescriptions, so even though the study participant was working and her income would be too high for a CSC, her regular healthcare costs were really difficult for her to meet.

In England and in other countries, people with chronic conditions are eligible for free or cheaper prescriptions. If National goes ahead with the plan to make those without CSCs or Gold Cards pay, they should anticipate ongoing pressure from patient advocacy groups to widen the criteria.

But the risk of widening the criteria too far is you end up with an expensive bureaucratic system to gather revenue from a small minority of prescriptions. In England there are a lot of exemptions, so more than 88 percent of prescriptions are provided free of charge. The ongoing political pressure and expensive bureaucracy could be avoided by keeping prescriptions free for everyone.

It is unclear how National’s system would run in practice: will patients have to show a physical card? Or will an automated system allow pharmacists to check patients’ CSC status? What happens when people’s status changes?

Cards get lost (especially by people living in insecure housing), or people forget to bring them. In our study we provided a study ID card to people whose prescriptions we were paying for. But often people picked up medicines for family members or others, so they didn’t have their study ID card.

The system of assessing eligibility may be so costly to set up it outweighs the revenue recovered from reintroducing charges. It is likely that most of the administration will fall on pharmacists, so instead of focusing on patient care, these highly trained professionals will spend their time on bureaucracy.

A report published this month by the Prescription Access Initiative found that since prescription charges were removed, on average each pharmacy spent over 10 staff hours less on copayment-related tasks each week

They described multiple benefits for all patients from this time saved. In our research we have heard of many pharmacies that used to run complex accounts systems where people paid off prescription charges over time. These were the only way many people could get the medicines they needed, but were sometimes the cause of arguments and tensions between staff and patients, damaging relationships and making it less likely that patients felt comfortable seeking advice or discussing their medicines.

There are many arguments for and against universal versus targeted government spending, and this probably should be decided case by case. With $5 prescription fees, the charge is low, the cost of providing universal access is not high, but the risks (missing people out, ongoing political arguments, damaging pharmacy services) are significant, so we urge the incoming government to keep prescriptions free for everyone.