2 – What is a Cure Worth?

🇨🇦 Canada:

Provincial public drug plans

Canada’s system is provincial, not federal, which creates variation, but the underlying logic is consistent.

Provincial public drug plans cover RA biologics for eligible patients with patient co-payments typically ranging from CAD $2 to $25 per prescription (often covered by the pharmacy). The government absorbs the rest.

Canada has pursued biosimilar transitions aggressively: British Columbia’s Biosimilars Initiative alone saved CAD $732 million over five years by mandating transitions from originator biologics to approved biosimilars. Ontario, Alberta, and most other provinces have followed. Where the US still argues about whether biosimilars should be substituted, Canada has settled it and is reinvesting the savings.

For CAR-T, Health Canada approved the first cancer CAR-T products in 2019 and 2020. Provincial coverage decisions vary; some provinces cover them fully, while others require exceptional access applications. No provincial plan yet covers autoimmune CAR-T, because none is approved.

🇬🇧 United Kingdom:

NHS

Biologic therapy for RA costs the NHS approximately £10,000 per patient annually. Abatacept, one of the most commonly prescribed second-line biologics, was explicitly described in a King’s College London Lancet trial as costing “about £10,000 per patient per year.”

NICE approves drugs under strict cost-effectiveness thresholds — typically £20,000 to £30,000 per quality-adjusted life year. A drug that costs £10,000 annually and delivers moderate quality-of-life improvement tends to clear that bar.

A one-time treatment costing £400,000 does not clear it using the same formula.

The formula is wrong.

🇩🇪 Germany:

Gesetzliche Krankenversicherung (GKV)

Germany’s statutory health insurance system covers approximately 73 million people. Reference biologics for RA (the original branded versions) cost up to €15,000 annually.

Biosimilar competition following patent expiry has driven some adalimumab costs below €5,000 per year. The GKV operates a centralised benefits assessment body (IQWiG) designed for comparative drug assessment, not for evaluating one-time curative interventions.

🇫🇷 France:

Assurance Maladie

France’s public health system covers approximately 93% of healthcare costs for severe chronic diseases, including RA. Annual per-patient biologic spend runs €8,000 to €12,000.

France’s Haute Autorité de Santé (HAS) uses a five-tier clinical benefit rating. CAR-T’s data (drug-free remission in 84% of lupus patients, 9 of 10 RA patients) would likely be rated as a major added benefit.

Whether the reimbursement structure can accommodate the price is a separate question that hasn’t been answered yet.

🇦🇺 Australia

Pharmaceutical Benefits Scheme (PBS)

The PBS lists biologic DMARDs for RA at highly subsidised patient co-payments, typically AUD $31.60 per prescription at the general rate, with the government paying AUD $15,000 to $25,000 annually per patient.

Australia was one of the first systems to approve CAR-T for blood cancers. Its willingness to extend that framework to autoimmune disease will be instructive.

🇯🇵 Japan

National Health Insurance (NHI)

Japan covers RA biologics, with patients paying 10–30% co-payment. Japan approved its first CAR-T therapy in 2019 and has a structured cell therapy pathway. It has one of the world’s highest rates of biologic use in rheumatology and large RA patient volumes.

The lifetime calculation every government will eventually run

Here is the arithmetic that no health technology assessment body has yet published, but all of them will. And it does not start with the drug cost.

A patient diagnosed with RA at age 35 starts biologic therapy. She stays on it, with periodic drug switches due to loss of efficacy, for the rest of her working life. That is one visible number. But when she goes on long-term disability, and 1 in 3 RA patients becomes work-disabled within 5 years of diagnosis, the government’s fiscal exposure does not just grow. It inverts.

The government stops receiving her income tax and social contributions. In Germany, the average worker contributes approximately €20,000 annually in combined income tax and social contributions. In the UK, the equivalent figure is approximately £12,000 to £16,000 depending on earnings.

The government starts paying disability benefits. In Germany, the average erwerbsminderungsrente pays approximately €900 to €1,400 per month — €10,800 to €16,800 per year. In the UK, Employment and Support Allowance combined with housing benefit can reach £9,000 to £14,000 per year.

Healthcare costs rise. Work-disabled populations are heavier users of the healthcare system across all conditions, not just the primary diagnosis.

This is the calculation that transforms the economics entirely.

The break-even point is not drug cost versus drug cost. It is the year at which CAR-T’s one-time cost is recovered through everything the government stops spending and starts receiving again.

That full fiscal benefit — drug saved, tax recovered, disability avoided — runs to approximately £35,500 per year for an NHS patient returning to full employment, and €48,800 per year for a German patient on reference biologic pricing. Against a one-time CAR-T cost of £400,000:

The break-even point is Year 11 at UK pricing. Year 8 at German reference biologic pricing. Year 10 at German biosimilar pricing.

Every year after that point is pure fiscal recovery.

By year 30, the NHS net saving is approximately £665,000 per patient. Germany’s net saving reaches €764,000 to €1,064,000 per patient depending on drug pricing. At even modest volumes, 10,000 NHS patients treated,  that is a £6.7 billion net fiscal gain over a generation.

The one-time treatment cost does not look like a cost at all. It looks like a government bond — with an eight-to-eleven-year payback and thirty years of compounding return.

The accountants running drug-versus-drug cost-effectiveness models are asking the wrong question, because the frameworks were built for a world where nothing cures the disease.

That world has ended.