Ryan Reynolds, Canadian?
Why does the U.S. Food & Drug Administration (FDA) care if my Viagra comes from Canada? Surely, the country that produced ersatz Americans, such as Ryan Reynolds, Michael J. Fox and Rick Moranis, could be relied upon to produce our drugs, as well.
The first problem is that not all Canadian drugs come from Canada. Just because a website has a maple leaf on its landing page doesn’t mean you can assume an internet pharmacy is selling drugs initially intended for the Canadian market.
In fact, if you traveled to Canada, you would never run into one of these pharmacies, because they are largely virtual. No brick-and-mortar Canadian pharmacy would ship medications directly to a patient in the U.S. It’s against the law—at least, if the American patient is using an American prescription. Canada requires Canadian pharmacies have a Canadian prescription.
So how is the grandmother in Boca getting her inhaler from Canada? The legitimate Canadian pharmacies pay a Canadian physician to rewrite the prescription, thus satisfying the letter, but not the spirit of the law. Given the profit motive, one could imagine that less reputable internet pharmacies may seek to maximize profits by further outsourcing these prescriptions to other countries. Thus, the drugs your patient orders from a purported Canadian pharmacy may actually be coming from India.12
That’s the point. The FDA barely has the resources to police the manufacture of generic drugs legitimately sold in the U.S. It does not have the resources to police the internet pharmacies now cropping up. In a 2005 sting, the so-called Bait and Switch operation, the FDA found the majority of drugs being sold as Canadian either did not originate in Canada or were counterfeit.13 Although driving across the border to purchase drugs in a brick-and-mortar Canadian pharmacy is perfectly safe, at least some of our patients who believe they are purchasing Canadian drugs through the internet are being catfished. Caveat emptor.
It will surprise no one to learn the U.S. pays more for medications per person than most other countries, even when the use of said medications is about the same. What is everyone else doing that we are not?
Getting state governments involved would obviate this problem. By purchasing drugs directly from Canadian wholesalers, the provenance of the drugs would be assured. Florida is now working with the states of Vermont and Colorado to create a single purchaser representing almost 30 million people. Kaiser Permanente, by way of comparison, serves 12.3 million people, and the VA serves 9 million veterans annually. A FloVeCo purchasing block would have quite a bit of leverage at the negotiating table.
Is this really the way forward? Maybe. The gradual legalization of marijuana across the U.S. demonstrates that state legislatures are willing to tackle sticky issues the federal government would rather ignore.
Of course, purchasing drugs from Canada is not a long-term answer. Canada is a nation of 37 million, making it roughly the size of California in terms of population. It simply doesn’t have enough drugs to share. American demand for drugs, funneled through Canada, could also lead to an increase in Canadian drug prices. Also, I’m not a legal savant, but I would assume drug companies could stipulate in their contracts that wholesalers not contract with American governments in exchange for even more favorable pricing. From a purely economic standpoint, it would be like writing off California to retain free access to the markets in the other 49 states.
Finally, it has not escaped anyone’s notice that there is a certain irony in this strategy. Many of the most expensive drugs being discussed are actually manufactured in the U.S. For reasons that make no sense, drugs that make a quick trip across the border cost less than drugs purchased directly from American manufacturers.
In mathematics, there is the concept of the lemma, also known as a helping theorem, which is a proposition that must be proved to get to a more important result. These new laws are lemmata that prove that state governments can work together to address the cost of drugs in the U.S. The next step will be creating coalitions of state governments that can negotiate prices directly with the pharmaceutical industry. This will likely require a sea change in how drugs are priced in the U.S., which will impact pharmaceutical voucher programs and pharmacy benefit managers. We may also need to readjust our own expectations regarding our right to have access to the most expensive drugs immediately after they come to market.
That said, it is pure insanity that any American should suffer because they can’t afford to purchase insulin or an epinephrine auto-injector. I don’t want anyone to break the law, but given the tremendous need, we should ask our laws to bend.
