28 The Americas The EconomistFebruary 15th 2020
21scription drugs, which is around C$34bn
($26bn) a year. By 2027 Canada would
spend 10% less than currently projected.
That is because the federal government
could negotiate lower prices for bulk pur-
chases of drugs, said the panel. It could also
speed up the switch to (much cheaper) ge-
nerics when patents expire. Employment
costs would fall by C$750 a year per worker,
because employers would no longer feel
obliged to pay for drugs. Other things being
equal, this should translate into higher
wages. Families’ out-of-pocket expenses
would also fall by C$350. Other health-care
costs would also drop. Patients who skip
medication tend to get sicker and need to
go to hospital. This is much more expen-
sive than taking the drugs would have
been, and the taxpayer picks up the tab.
But Mr Trudeau is wary of an ambitious
national plan that would push up federal
spending. The advisory panel reckons that
universal coverage would eventually
cost the federal government an additional
C$15bn a year, more than half this year’s ex-
pected budget deficit. It would probably
also lead to an increase in taxes. Opponents
make an argument that will sound familiar
to Americans: people with private insur-
ance get better coverage than they would
under a public scheme. As in the United
States, few Canadian workers realise that
the high cost of employer-provided health
insurance comes out of employees’ wages,
collectively.
Provinces and territories, which are in
charge of public health care, might also re-
sist drug reform. In 2011 the federal govern-
ment, then led by the Conservatives, cut in
half the annual increase in its contribution
to provincial and territorial health bud-
gets. Provincial governments suspect that
pharmacare will be used to dump more
costs on them. It is the “most expensive
and disruptive option” for provinces, says
Tyler Shandro, the health minister of Al-
berta, a western province governed by Con-
servatives. Provincial leaders have already
said they want the right to use the money
that would be spent on universal pharma-care for their own health-care priorities.
Before the election Mr Trudeau prom-
ised a C$6bn “downpayment” on pharma-
care over four years, far less than needed
for a universal programme. Support for a
more modest plan could come from the-
Bloc Québécois, a nationalist party from
Quebec that has more seats in Parliament
than the ndp. Quebec is the only province
with universal public coverage for citizens
who lack private insurance. The Bloc is un-
likely to endorse a federal programme that
replaces it.
The government has begun an econ-omy drive. It is lowering price ceilings by
removing the highest-cost countries, such
as the United States, from federal bench-
marks. That will reduce national spending
on drugs by a modest C$130m a year on av-
erage over the next decade, it expects. The
government also plans to establish a na-
tional drugs agency to improve co-ordina-
tion with provinces in bargaining with
pharmaceutical firms and to consider ways
to standardise and expand drug coverage.
But this may take years. Until then, Canada
will not be quite the role model that Mr
Sanders thinks it is. 7There’s no pill for that
Pharmaceutical spending, % of GDP
Selectedcountries, 2018 orlatestavailableSource:OECDBritainMexicoAustraliaFranceGermanyCanadaJapanUnited States0.50 2.01.51.0N
ayib bukele, the president of El Salva-
dor, draws notice outside his country
for his youth, his jet-black beard and his
mastery of social media. Now his authori-
tarianism is a trending topic. The sight of
Mr Bukele entering the National Assembly
on February 9th, alongside soldiers toting
machine guns, shocked onlookers at home
and abroad. He plonked himself in the
empty chair reserved for the president of
congress. “I liked seeing those empty
seats,” he tweeted. “It made it easier for me
to imagine them full of honest people who
work for the people.”
Congress accused the president of stag-
ing an “attempted coup”. The Constitution-
al Court rebuked Mr Bukele. El Faro, a Salva-
dorean news website, called his stunt “the
lowest moment that Salvadorean democra-
cy has lived in three decades”. He retorted,
not very reassuringly, “If I were a dictator, I
would have taken control of everything.”
Eight months into his presidency Mr
Bukele, who at 38 is the world’s second-
youngest head of state, has an approval rat-
ing of 90%. But his left-leaning New Ideas
party, founded in 2018, has not had a
chance to win seats in congress. The legis-
lature is dominated by two parties: the left-
wing fmln, the successor to a guerrilla
movement that fought a decade-long civil
war in the 1980s, and the right-wing Arena
party, which defended the government in
that war. Mr Bukele has so far used his pop-
ularity to get his way in congress, persuad-
ing it to enact a budget, for example.
But for three months the legislature has
failed to approve a loan that would finance
Mr Bukele’s security plan. Tired of waiting,
he ordered lawmakers to convene for an ex-
traordinary session. When no quorum was
reached, he summoned the army and thou-sandsofsupporters,invokinganarticleof
the constitution that gives citizens the
rightto“insurrection”.
Congress had already consented to
morethan$400mofspending forhissecu-
rity plan, whichincludes astrategy for
fightinggangs,moremoneyforsocialpro-
grammesandanupgradeofequipmentfor
the police. Sofar, though, congresshas
withheldapprovalofa $109mloanfromthe
CentralAmericanBankforEconomicInte-
gration,a multilateralbankbasedinTegu-
cigalpa,Honduras,tobeusedtobuyequip-
ment. Some lawmakers worry about
reportsthata $26mcontracttosupplycam-
eraswillgotoa MexicanfirmthatgavefreeA popular president summons the army to bully the legislatureEl SalvadorBukele up
It’s going to be a bumpy ride................................................................
Award: Our Brazil correspondent, Sarah Esther
Maslin, received a NEXTaward for journalists under
30 from the American Society of Magazine Editors.