Black patients in Canada are significantly less likely to fill their prescriptions for reasons related to cost than their White counterparts, according to a new study.

“Our results also indicate that Black people are less likely to have prescription drug coverage,” senior author Oluwabukola Salami, PhD, professor of community health sciences at the University of Calgary, Calgary, told Medscape News Canada. 

Though the study was not designed to determine the reasons for higher cost-related nonadherence among Black individuals, the data suggest that the reasons are likely related to insurance status, employment status, and income inequality, she added.

The findings were published on March 23 in CMAJ. 

No Universal Prescription Coverage

“In Canada, we have universal healthcare coverage, and someone can see a doctor 10,000 times, but if they do not have the money to buy the medication, their health will not improve,” Salami said. Canada is the only high-income country with universal healthcare that does not also have universal prescription coverage, according to the researchers.

Therefore, “pharmaceutical coverage policies vary by province, leading to differences in out-of-pocket expenses and catastrophic drug costs,” the authors wrote.

The researchers studied data from the Canadian Community Health Survey for 2015, 2016, 2018, 2019, and 2022. The analysis included 181,511 adults, with 2997 Black and 178,514 White participants. The rate of cost-related prescription nonadherence in Black adults ranged from 15.3% in 2015 to 9.5% in 2022 compared with about 6% in White adults over the same period. Fewer Black adults than White adults had insurance coverage for prescription medications (72% vs 80%-83%).

After adjusting for potential confounders, Black cultural or racial background remained linked with cost-related prescription nonadherence (adjusted prevalence ratio [PR], 1.36). Having prescription medication coverage was associated with a lower likelihood of not filling medications because of cost (adjusted PR, 0.44).

Before this study was conducted, “there was no research on medication adherence among Black people [in Canada], and that was our impetus for doing this. Future pharmaceutical policies must consider both race and income inequality as social determinants of health,” said Salami.

Similar disparities have been identified in the US, “where 35.1% of Black Medicare beneficiaries reported cost-related prescription nonadherence,” the authors wrote.

A Public and Private Patchwork

“These numbers are both not surprising and important,” Steve Morgan, PhD, professor of population and public health at the University of British Columbia in Vancouver, told Medscape News Canada.

“We’ve known for a long time that our patchwork of private and public insurance for prescription drugs creates vulnerabilities for patients with low incomes and patients of ethnic minorities and racial identities,” he said. “This is a very well-done and detailed study of Black Canadians,” he added, noting that conducting such a study is inherently difficult because of the relatively small numbers of Black people in Canada.

Several factors are important to consider, he continued. One is “the economic shock” of the COVID pandemic and the move to a gig economy with work that typically doesn’t come with insurance coverage. “It is possible and likely, given the structural inequities in society, that people who are Black in Canada have a greater likelihood of being employed in sectors that are more precarious and less likely to offer health benefits.”

People with higher incomes working for larger, often unionized, companies are more likely to have health insurance benefits. “It is more likely that the people in those employment environments are non-Black,” Morgan said. “There are also subtle and not-so-subtle forms of racism in Canada’s healthcare system and in our society writ large” that may lead to questions about whether a patient is using a medication appropriately and to cultural differences in lack of trust in providers, he added.

While this study should be viewed as an important step in helping understand those issues, more studies are needed to assess the factors that lead to nonadherence across all patient groups, said Morgan.

The best evidence-backed roadmap for heading toward universal prescription coverage and eliminating financial barriers to prescription adherence in Canada is the final report of the Advisory Council on the Implementation of National Pharmacare 2019 report, Morgan said.

“That will be a monumental step in the right direction,” he said. “But the momentum toward implementation of the recommendations in that report was derailed in large part by the COVID-19 pandemic. And now the federal government’s focus is trying to keep the Canadian economy stable in a time of economic and political crises,” he said.

This study was funded by Alberta Innovates through the LevMax program and by the Canada Research Chairs Tier 1 program awarded to Salami, with support from the Canadian Institutes of Health Research (CIHR). Salami reported being cochair of the Public Health Agency of Canada Advisory Committee on Science, a member of the Governing Council of the Social Sciences and Humanities Research Council of Canada, and an advisory board member with the CIHR Institute for Human Development, Child and Youth Health. Morgan reported having no relevant financial relationships.

Marcia Frellick is an independent healthcare journalist and a regular Medscape Medical News contributor.