An American Sickness: How Healthcare Became Big Business and How You Can Take It Back

Currently, there is no way for American patients to easily identify the cheapest prescription drug vendors. There is also very little regulation of drug pricing: the cost and copay of a lifesaving medication could change from month to month, and many patients do not learn this until they are already picking up their filled prescriptions. A 2015 poll revealed that 72% of Americans “considered drug costs unreasonable” and 25% reported having “a difficult time paying for their drugs, a proportion that rises dramatically for people who are poor or in poor health” (302). This problem can only be overcome with legislation, and considering Congress’ perpetual state of partisan gridlock, it is important for patients to understand how they can adapt to the reality of the situation.

Patients can often reduce drug costs by learning about certain active components. Certain prescription medications are combinations of older drugs or repackaged versions of older formulas. Increased cost does not always indicate increased functionality. Oftentimes, research will uncover cheaper generic alternatives. There are workarounds patients can pursue if that is an option. Some patients will elect to select a higher dose of a drug (if it is on an insurer’s formulary) and will cut the pills in half. There are also certain platforms, like GoodRx.com, that will provide a medication’s cash price at a pharmacy and source coupons for discounts (though this is only applicable if a patient chooses not to use insurance).

Patients can also import a drug from a country they trust or with whose language they are familiar. This ensures that there will be no miscommunication about issues of dosage or quantity. If a patient travels with a prescription, an international pharmacist is usually willing to fill it. Patients can also utilize mail-order pharmacy programs for medications they need to use on a long-term basis. However, this is only advisable for drugs that do not require specific results, such as cholesterol controls. While this is technically illegal, the US government usually does not retaliate unless a patient orders more than three months’ worth of a medication.

Patients can also save money by treating healthcare advertisements with healthy skepticism. After America became one of two countries to permit drug commercials, regulators required manufacturers to disclose any side effects during the advertisement. This information is often relegated to a rushed voiceover at the end of the commercial. Manufacturers are also not required to compare a drug’s efficacy to similar options on the market. For this reason, patients should not decide to use medication based on an advertisement alone.

The current state of the drug market leaves much to be desired. Lawmakers must take steps to ensure all patients have equal access to the medications they need. One idea is officially legalizing the importation of foreign drugs. Though it is a crime that is infrequently persecuted, the pharmaceutical industry has frequently lobbied against this. Giving patients the legal means to source drugs internationally would also make the process safer. Americans could buy medicines from licensed pharmacies abroad (previous proposals have mentioned Canada, Great Britain, Australia, and Japan). They would also only be able to access medications vetted and approved by these countries’ versions of the FDA. The FDA should also accept the results of research carried about by its foreign colleagues. This would speed up the approval process and would encourage countries to cooperate in the pursuit of solving pressing medical issues on an international scale.

American patients would also be under less financial strain if pharmacists had more prescribing power. The results of this were evident in 2015 and 2016 when California and Oregon respectively passed legislation that allowed pharmacists to begin writing prescriptions for birth control pills. Previously, women could only receive birth control from their gynecologists, causing them to shoulder the massive cost of specialist visits in exchange for routine healthcare. Most states adhere to “medical society-backed ‘scope of practice’ laws,” which ensure that specialists have the most authority over prescribing medications used on a long-term basis (310).

Patients could cut medical costs if the FDA reformed the patent and device approval processes. Currently, research is the main revenue source for drugmakers. Manufacturers receive tens of thousands of dollars to study the impact of a drug before it even hits the market. In some situations, this has benefits. There are cases where “big profits from one drug [...] finance[s] a company’s future research,” meaning that “when a company gets quick approval for a drug to treat a rare disease and prices it at $30,000, profits can be used to study whether that drug will be a useful remedy for more common conditions” (311). However, it also enabled needlessly expensive drugs that provide no novel benefits to enter the market.

The FDA could combat this issue by maintaining comprehensive records of all existing patents that protect drugs on the market. Rosenthal titles this hypothetical compilation “The Orange Book.” The Orange Book would list every drug’s active chemical ingredients and “peripherals,” such as the technology behind a chewable tablet (311). Patents in the Orange Book would have to expire before a competing manufacturer could begin creating a generic. This would prevent needless litigation over patents that can prevent patients from getting the care they need.

Similarly, the government could refuse to issue patents for drugs that do not significantly improve on their predecessors and restructure the patent approval process to prioritize drugs that represent “a genuine medical breakthrough” (312). The FDA should also reduce the amount of required research studies manufacturers must perform on trial drugs so that higher quality products have the opportunity to enter the market. Lastly, drug companies should be required to seek approval if they plan to cease production on a particular medication. Patients who are not made privy to these decisions are often forced to scramble at the last minute to find alternatives to their medication.

The government can also negotiate national prices. Federal insurance programs such as Medicaid and the VA HMO can leverage their government ties to drastically curb prices for their policyholders. However, it is against the law for Medicare to follow suit. This is a provision drugmaker interest groups were able to sneak into a 2006 amendment to Medicare, arguing that the government’s power would dwarf their own, thus preventing future research opportunities. The government should consider rescinding this ban and adopting a system similar to the one utilized in Great Britain. Britain’s National Health Service (NHS) tells pharmacists any reimbursements they will get from carrying a particular drug ahead of time. They are able to calculate this based on government research on a drug’s worth and efficacy. Then, the pharmacists are able to source cheaper drugs from anywhere in the European Union. Congress could emulate this system by moving to calibrate American drug prices with those in countries with comparable economies. It could also rescind this provision and allow Medicare to directly negotiate with drugmakers.

Above all, the government must take any necessary steps to ensure that the pharmaceutical industry is transparent and cost-effective at all stages of the manufacturing, approval, and distributing processes. As it stands at the time of publication, “government bodies charged with the responsibility to ensure patient-centered healthcare cannot directly consider the pricing of treatments, medicines, or devices in their recommendations and deliberations” (315).

This provision was intended to ensure valuable treatments could still enter the market even if they are expensive. However, Rosenthal offers two theories that could ensure this is still the case while providing more protections to patients. The first is to mandate that manufacturers of drugs and medical devices include an estimated price point with their initial FDA application. Currently, the FDA can inquire about a drug’s cost but cannot consider it when deciding to approve or reject an application. There is room for compromise in this idea: even taking care to discuss cost throughout the development process could create enough publicity where drugmakers could be shamed into keeping a price stable. The second theory is to create an organization similar to the United Kingdom’s National Institute for Health and Care Excellence (NICE). NICE takes stock of the UK’s healthcare market to determine the value of emerging treatment options. The NHS uses this data to drive negotiations with drug manufacturers. In America, this sort of cost-benefit analysis is relegated to academia and can only be performed after a drug enters the market.