Florida just received approval from the FDA to engage in bulk drug imports from Canada. Florida believes that if they can buy a limited set of prescription drugs at Canadian prices, the state will save oodles and oodles of money. The state is relying on the Canadian willingness and ability to credibly say “NO, not at that price” to manufacturers and distributes to get these good prices.
The NY Times has details and the obvious objection:
Florida has estimated that it could save up to $150 million in its first year of the program, importing medicines that treat H.I.V., AIDS, diabetes, hepatitis C and psychiatric conditions. Other states have applied to the F.D.A. to set up similar programs.
But significant hurdles remain. The pharmaceutical industry’s major lobbying organization, the Pharmaceutical Research and Manufacturers of America, or PhRMA, which has sued over previous importation efforts, is expected to file suit to prevent the Florida plan from going into effect. Some drug manufacturers have agreements with Canadian wholesalers not to export their medicines, and the Canadian government has already taken steps to block the export of prescription drugs that are in short supply.
Price levels are a function of leverage and substitution-ability. The US has very few entities that can credibly threaten “No, not at that price…” to prescription drugs manufacturers. Pharmacy Benefit Managers (PBMS) perform this function with fragmented pools. The VA has substantial cost savings compared to Medicare Part D because the VA can credibly threaten to exclude numerous drugs:
To repeat, the key findings are:
- The VA pays 40% less than Medicare plans for prescription drugs.
- Medicare plans cover about 85% of the most popular 200 drugs on average (ranging from a low of 68% to a high of 93%).
- The VA’s national formulary includes 59% of the most popular 200 drugs.
<//blockquote>
Canada (and most other rich industrialized countries) have some set of systems that can far more credibly commit to “No, not at that price” or “HELL NO, NOT AT ALL” to manufacturers and distributers than the US.
Florida, and the other states that want to do bulk importation want to free ride on the costs that Canada pays to get Canadian price levels without having to say no directly.
I have a modestly strong belief that the Canadians and the drug manufacturers are unlikely to play ball to the extent that Florida and other American states think they will.
UPDATE: Some commentary from Dr. Stacie Dusetzina of Vanderbilt on this proposal. Dr. Dusetzina is one of the national experts on US drug pricing. Her opinion is that operationalization is going to be a challenge. She is also a friend, colleague, co-author and mentor for me:
Barbara
This is not going to work. This is not a scheme to import drugs. It is a scheme to import the benefits of regulation because we don’t have the courage or political will to adopt some aspect of pricing regulation on our own. Screaming about how unfair it is we subsidize research for the rest of the world is a big ho hum unless you are willing to do something about it.
scav
Well, pish, isn’t the FL Surgeon General attempting to save money by declaring vaccines — no doubt other drugs to come — as simply invalid on his sayso? Will Canada really object to offloading their strategic supplies of bleach and snake oil to avid pushers?
Barbara
Just to give you some facts and figures: Florida’s population is 21+ million, a little more than half of the ENTIRE POPULATION of Canada, which is just under 40 million. Manufacturers can control the flow of exports out of Canada by controlling the flow of drugs that are released for use in Canada. They can also simply refuse to sell drugs to entities that participate in importation plans.
Thor Heyerdahl
I’m sure many Canadians would greatly enjoy watching Trudeau pull DeSantis’ vest over his head and feed him a bunch of hockey fight uppercuts a la “Slapshot”.
Hey DeSantis ya weird smile white boot loser, take off eh!
Alison Rose
@Thor Heyerdahl: I would love to see DeSantis have some kind of meeting with Trudeau with press there. Then keep going! Just keep putting yourself next to men who are way better-looking than you and have ten million times the charisma, Ronnie. Newsom, Trudeau, how about Zelenskyy next while you lay out your brilliant plans to end the war, David Beckham’s got a soccer team down in Florida, go see an Arsenal match in England and get a selfie with Idris Elba…
RevRick
Right now, U.S. consumers are subsidizing the rest of the world with our inflated drug prices. This is legitimate and understandable in relation to Africa, but if Medicare’s drug price negotiations succeed, it will likely mean increased prices for Canada, Europe, Japan and South Korea.
West of the Rockies
I’m sorry, I appear to be having a stupid brain day. When you say, “No, not at that price!”, do you mean Canada is benificently saying, “We shall charge you less than we could because we like you”?
Thor Heyerdahl
@RevRick: at which point the country threatens to open generic production of the drug in question, or hints at increased scrutiny of new drugs the company is trying to release in that country.
Fake Irishman
@Thor Heyerdahl:
Trudeau is a legit boxer. He clobbered a Conservative MP in a charity match about 15 years back over some racist things the conservative said.
There is video somewhere.
@Thor Heyerdahl:
Thor Heyerdahl
@West of the Rockies: As I understood the sentence, Canada’s saying “not at that price” to the pharma company…not to the US
Thor Heyerdahl
@Fake Irishman: versus a young conservative senator Patrick Brazeau. Video here
Fake Irishman
@RevRick:
I would like to see some empirical evidence sorting out how much of the difference would come out of profit vs be reflected in increased prices vs being a bit of a slowdown in R&D. I’m sure an academic has done good work on it, but I don’t know the area.
Chetan Murthy
@Fake Irishman: The evidence is already there: pharma companies spend more on PR/marketing/advertising than on research/drug development. And that doesn’t include the *massive* subsidy we provide them by underwriting most basic research in the US. All we’re doing is subsidizing the mansions and yachts of pharma bros.
Ken
The link in “exclude numerous drugs” is bad.
I will be interested in seeing how this plays out. Capitalism and politics being what they are, if they start importing drugs, I’m guessing someone (probably a friend of DeSantis) will manage to insert themselves as a middleman and mark up prices to almost the US rate.
Fake Irishman
@Barbara:
Yep. And opening some of Medicare’s drugs to direct negotiation starts us down the VA path. Of course DeSantis would love to repeal that part of the Inflation Reduction Act if he became president. It’s almost like the 2024 elections matter.
Fake Irishman
@Chetan Murthy:
Oh, I totally believe that is likely the case, I would just like to see an actual series of studies quantifying numbers.
FelonyGovt
OK you win the Internet today. 😀
Brachiator
It amazes me that conservatives oppose efforts by the federal government to get drugs at lower prices, but applaud similar efforts by Florida. Isn’t this the socialism that conservatives claim to dread?
I didn’t realize that the VA had a much better deal with respect to drug prices than Medicare.
Is this really a free ride? Does it matter where drugs come from if they are high quality? Canada could increase production or even charge a slightly higher price for US drugs and still make everybody happy.
I think that both US and Canadian drug companies are happy with the status quo. I have no problem if states can shake things up.
I recall that when people tried to buy Canadian or Indian drugs on the Internet, the US drug companies pushed the lie that these drugs were low quality or unreliable. Web sites got shut down for all kinds of dubious reasons.
Finally, the drug companies wrote tax law and passed it along to the GOP for final approval. Individuals cannot deduct prescription drugs from foreign sources on their tax returns.
Here’s the skinny from IRS Publication 502
US drug companies are not special entities that deserve to have their profits specially protected.
eclare
@Thor Heyerdahl:
That is also my understanding, although it took me a while to figure out who Canada is saying “no” to.
bbleh
I have a modestly strong belief that the Canadians and the drug manufacturers are unlikely to play ball to the extent that Florida and other American states think they will.
I have a stronger concurring belief. At best there will be SOME LIMITED exchange, subject to substantial constraints, mostly to try to paper over the disagreement to some extent rather than have a big public p*ssing match.
BUT … it doesn’t matter. This isn’t an attempt by DeSantis or his administration to save the state money or to provide healthcare to residents of Florida at a more affordable price. It’s an attempt to LOOK like they’re TRYING to do that, in a way that there’s someone to blame when it fails.
There is a widespread belief, especially among, ahem, lower-information types, that “Canada” equals “cheap drugs,” via some sort of foreign magic (maybe it’s the French part…?) , and that all one needs to do is ship them across the border and … profit! The more complex realities of the situation (eg, if that would work, why isn’t WalMart doing it? not to mention your local pharmacy?) don’t penetrate. They want to believe, so they believe. MAGA!
Chetan Murthy
@Fake Irishman: https://www.google.com/search?q=pharmaceutical+company+marketing+versus+research+expenses&gs_ivs=1#tts=0
Anoniminous
@Fake Irishman: There’s no relation between drug prices and scientific research because the drug companies haven’t done research since the 1980s. Biological research – writ large – is funded by the Federal government.
Current Model for Financing Drug Development: From Concept Through Approval
Doug R
Speaking as a Canadian, we don’t mind helping a neighbour out BUT we don’t want to SUBSIDIZE a state with a population OVER half our size scooping drugs at prices we negotiated that should go to Canadians.
Alison Rose
@bbleh:
Sacré bleu!
Omnes Omnibus
@Barbara: It’s sounds like a diversion program. Highly frowned upon by manufacturers and regulators alike.
Brachiator
OT. I think a small earthquake is rumbling through parts of Southern California.
lurker
@Brachiator: there are a bunch of comments here, this one included, which suggest a misunderstanding of the situation:
the drug companies make the drugs (e.g. ibuprofen/Advil) as an example. Where they make them is not really the issue. The drugs as made by the drug companies are then sent to wherever they go. If they go to Canada, the drugs are available in Canada, mainly through the Canadian national health care system, at a price based on what Canada as a country negotiates with the drug companies. The drug companies negotiate with Canada because a population of 40 million people (using an above estimate) is not to be ignored and they will get some profit. However, Canada will not pay the same list price for a drug that a smaller provider in the US will pay. For example, Kaiser is one of the bigger providers out there, but might have 1 million people it is caring for, so it cannot negotiate as effectively as Canada can.
Florida is saying that they will import drugs from Canada to take advantage of Canada’s negotiation prowess in its socialized medical system, and is also attempting to not have to negotiate directly with the drug companies about the price of drugs going to Florida, so the state can protect its free market anything goes image and DeSantis can continue tilting at windmills in the form of a presidential run. So Florida is attempting to free ride on the efforts of Canada. This is similar to the raises autoworkers at non-union plants got after the big strikes that caused the automakers to raise union wages – the non-union workers free rode on the union efforts, in this case due to automakers deciding they did not need the threat of more union members in the south where the non-union plants are.
If Florida negotiated directly with the drug companies, it would be like a smaller version of Medicare doing the negotiations, and the drug companies have been fighting this type of proposal since at least the 1990s, probably longer. They had to give in on the VA due to the PR aspects, but even there it was a fight. Similarly, if the US started limiting prices of drugs all of the insurance companies would attempt to get similar deals and the drug companies would then see revenue decreases from Kaiser, Blue Cross/BlueShield, etc. They (drug cos) are not willing to give up revenue without a fight, regardless of what they spend it on (R&D, lobbyists, advertising/PR, etc.) so we get to a point where a strong entrenched effective cartel works hard to protect the market they have developed.
Yarrow
If Canada agrees to this then won’t every other state want the same deal? That doesn’t seem like it would work out for Canada. Maybe Canada can say they have a “special American price” for states.
Oooh, maybe DeSantis will blame Canada and start demanding we build a wall on our northern border.
trollhattan
@Thor Heyerdahl:
I’m sure Justin would win the chirpin’ game over Ronny too, eh?
RaflW
I remember when Governor Hockey Hair (Tim Pawlenty) tried a related effort around 2003-4. It’s amazing to me the lengths to which Republicans will go to prevent Medicare from gaining that 40% discount that the VA already enjoys.
It’s plain as day to me that the goal here is to have Medicare look ‘too expensive’ and bureaucratically stymied. But it isn’t. It’s politically hamstrung by GOPs (and pharma lobbyists).
lurker
by the way, I think the technical term used by Mr. Anderson (maybe) in the past for part of what the drug companies spend their money on was something like ladies of the evening and illicit substances … or something to that effect … some of which is likely spent in the various entertainment clubs of Tallahassee, Miami and other parts of Florida, potentially…
Alison Rose
@Brachiator: A 4.1 in some little CDP called Lytle Creek, about 20 miles NW of San Bernardino.
bbleh
@RevRick: @Thor Heyerdahl: @Fake Irishman: @Chetan Murthy: @eclare: @Brachiator: @lurker: as always, the reality is somewhat more complicated. It’s true that pharma “marketing and sales” expenses are scandalously high, which is in part but not entirely due to the relaxation of the (effective, not actually legal) ban on pharma advertising thanks to the work of the Holy Office of Deregulation under Saint Reagan. Almost EVERYONE — pharmacos very much included, although obviously not advertisers — would be better off if it were re-instituted.
But it’s not across the board. A HUGE chunk of it is in very large markets where there is head-to-head competition. Think Ozempic/Wegovy vs Mounjaro for weight loss, or earlier battles over RA drugs like Vioxx vs Celebrex. It becomes an “arms race,” where neither side can afford to back off, and both face incentives to increase spending, but the market shares don’t change much if at all, and they likely wouldn’t change much if all the advertising suddenly went away. It’s basically wasted money. For drugs in such markets, M&S spending can easily exceed R&D.
But it’s NOT the case for MOST drugs. Most drugs do very little marketing (how many of the drugs you take do you hear/see regular ads for?). For most drugs, R&D is still the biggest item, and for “small-molecule” drugs really about the only item.
The other thing to keep in mind is, what is counted as “marketing and sales” expenditure sometimes includes the discounts that are routinely offered to … well, almost everybody, and those can be very high — 40%-50% or even more off “list price.” They’re so big, they’re treated entirely separately in some accounting, as sort of “reductions in revenue” rather than as expenses. Gotta be careful what you’re counting.
And lastly, I think Rev Rick is correct at 6, when he says that bringing US prices down to world levels (which would require major structural change in the US market btw) likely would be offset somewhat by increases elsewhere, although it would take time because of the way “acceptable” prices are determined in many countries (it’s NOT just negotiation, the way it mostly is in the US). So it would be good, but there would be a few dark streaks.
Martin
California’s state-produced insulin should hit the market this year. $30/vial, no insurance needed. Pharmacies in the state are required to stock it (this is designed to prevent PBMs from manipulating the market availability).
Naloxone (Narcan) is next.
Searcher
Besides the whole “hating Canada’s medical system but wanting to be a part of it”, I feel like phoning it in is basically another signature of conservative government at this point.
They can’t govern, they can’t propose legislation that isn’t just boiler plate written for them by ALEC, they can’t even *read* the damn bills they’re supposed to vote on, everything is just *too hard*. So they outsource it, to the Federalist Society, to ALEC, to goddamn Canada.
Brachiator
@lurker:
Nothing that you have written disagrees with anything that I wrote.
Comparing what Florida is trying to do with Kaiser, a single health care provider, is pointless.
Florida is trying to get a free ride. So what?
The brief period when individuals could order Canadian drugs was quickly shut down because US drug companies wanted to control its market.
They reinforced this by changing tax law.
Barbara
@bbleh: The point is that those countries protect themselves and the U.S., until very recently, doesn’t even try. We can’t worry about what the impact will be in Germany or wherever. They are certainly indifferent to the impact their own pricing methodology has on us. By the by, Germany conducts something of a “value based” compensation analysis that helps inform what a drug is worth. Other countries engage in different kinds of analyses. There is no direct relationship between what they do and what we do and no reason to predict a specific price outcome.
Hoodie
“Ron DeSantis agrees: Socialized medicine works!”
Barbara
@Brachiator: Look, not to put too fine a point on it, “Florida” even under this proposal ISN’T BUYING DRUGS, and at least the proposal I reviewed a few years ago has no concrete plan to give the benefit of such lower priced drugs to consumers. Consumers get drugs at pharmacies, which buy drugs from wholesalers and get reimbursed by public and private payers. Where in this model does the state plan to give consumers the benefit of lower prices? Most likely, if there is a benefit it will go to employer funded health plans or the usual suspects. I am sure Florida will try to ensure that its Medicaid program benefits, but I didn’t see how when I looked at their original proposal.
bbleh
@Barbara: yes, they — and to an even greater extent the UK and other Anglophone countries — conduct “cost effectiveness” analysis, in which the healthcare “bang” per pharma “buck” is compared to the existing standard of care. For a new drug to be approved at a proposed price, the improvement in healthcare per unit cost must be better than what’s already available.
( … mostly — there are always exceptions for various reasons.)
(And yes, the US can and should do much the same, but “cost effectiveness” was a Very Bad Thing To Say in the US for a long time (although that’s changing). And of course, there are/were even worse barriers, like the (now obsolete) prohibition on price negotiation by Medicare (!!))
And that’s why I said it would take time for other countries’ prices to reflect changes in US prices: the prices across entire therapeutic markets would have to change. But eventually they would, as new mechanisms and systems replace old ones, and the old standards of care simply become obsolete.
BUT, there certainly IS a direct relationship between their prices and ours, via the pharma companies who manufacture and sell the drugs. They can control supply almost entirely (although not completely, thank you EU), and while country ops are typically disaggregated, brand teams and corporate people look at worldwide revenue too. If country X starts demanding too low a price for a drug from a pharmaco’s point of view, country X can find itself with little or no access to the drug.
David_C
Something day job related!
@bbleh: (and Lurker) are on the right track. It’s a bit misleading to say that the Federal government pays for R&D costs of drug development. Initial, non-GLP research is a fraction of the cost of GLP non-clinical safety studies, scale-up under cGMP conditions, and clinical studies. Failure can happen anywhere along this pathway.
Martin
@Brachiator: The VA basically negotiates drug prices for all federal agencies that buy directly (DOD, Bureau of Prisons, Public Health Service, Indian Health Services, NASA, etc.) simply due to their size, plus the fact they have a single formulary because the VA employs their own doctors and they’ve developed a single set of prescribing rules. So they can also negotiate dosage sizes and things like that, which carry down to the other federal agencies, since everyone uses the VA formulary. And because so many medical doctors intern at the VA before going off to their careers, the VA formulary is kind of the starting point for all other formularies in the country.
Medicare does not get to piggyback on the VA, though. They have to do their own negotiation, which is bullshit, because they won’t get as good deals as the VA does.
California has been single-payer curious for a long time now – and has generally rejected the Florida route as being unsustainable in part because there are lots of accounting mechanisms that can be employed in those negotiations, and likely will be employed if drugs start being exported. Canadian taxpayers don’t want to subsidize Florida residents, so you might expect a change to these contracts that results in a higher cost per drug combined with a taxpayer kickback just for the drugs sold in Canada, that kind of thing. That’s why CA opted to manufacture in state. I still think the state should have done it directly rather than through Civica, but Civica gets the ball rolling a lot faster.
Brachiator
@Barbara:
From the NY Times article.
The Biden administration has cautiously approved what the FDA is doing.
Why are people here objecting? Do they only support this if it is part of a federal “Medicare for All plan?”
Martin
@David_C: According to the NIH, they funded 99% of approved drugs from 2010-2019, at an average value to the drug company of between $2B and $3B per drug.
Industry is not spending more than NIH on drug development:
Brachiator
@Martin:
This was the 2019 executive order and 2020 law. The first drug coming through this plan is insulin. Has production actually begun?
Do you know what the EU is doing, if anything, related to dealing with the costs of prescription drugs?
Barbara
@Brachiator: If we want lower cost drugs we should enact our own laws and programs to get them. This is like me proposing to drive from Washington D.C. to New York City via Chicago. It’s a long way around to arrive there later than I needed to and at a much higher cost and risk of harm than if I had taken a straight path. And I did review the various proposals. Not a single one of them guaranteed lower costs to consumers. Not one. Hospitals might benefit, Medicaid programs might benefit, and so on, and this should be unsurprising because of the level of fragmentation at the consumer and payer level.
Martin
@Brachiator: I object to outsourcing critical functions to 3rd parties. I mean, that’s the primary objection to privatization.
If the US wants to negotiate drug prices, don’t outsource that to Canada, which has less negotiating power than California does. If the federal government is unable to do this, address that problem directly. If the federal government wants states to negotiate, then don’t send them to Canada, let them negotiate individually or collectively in the same manner that CA bands together with 2 dozen other states on CARB and other regulations.
I mean, if Canada is the functional government here, maybe we should just have them annex us.
wjca
Only a 4.2, according to the USGS. Californians rarely get excited until 4.7 or so.
Brachiator
@Barbara:
So, you are saying that the Biden administration and the FDA are wrong to pursue this strategy? This is fundamentally a bad policy?
bbleh
@Martin: [horrible screeching sound heard suddenly from the north, followed by rising chant of “Build! The! Wall!”]
Brachiator
@wjca:
I’m a Californian. I noticed a rolling motion in my home. I get excited if the motion increases and goes on for some time.
For example, the Japan quake got my attention because the videos showed the quake going on for a significant time.
I have been through quakes that damaged property and caused injuries. I have never been through a quake that went on as long as what I saw.
lurker
@Brachiator: most of what we have written is in agreement.
it seemed to me that you asked directly if Florida was trying to get a free ride, and I explained that in my opinion Florida is trying to get a free ride. I think we both understand that is not the biggest issue here, but several commenters here have pointed out that Republican run state governments have a number of arguments against the general concept of free riding, tampering with markets, or otherwise doing anything but operating in the market on your own merits (at least for individuals). So the free ride is yet another bit of R hypocrisy. Beyond that, the inability to govern comes through with this whole scheme – we cannot take on the drug companies or reform our own systems, but we can try to take advantage of those far off Canadians…
Additionally, as my comment mentioned at the beginning, while I tagged your comment, I was addressing a number of comments that had already shown up, which seemed to suggest in various ways that Canada produces its own drugs and we are trying to get them from Canada the drug maker. I could have tagged half a dozen commenters as I sometimes do, but I was in a hurry and knew I did not have time to write a short comment already, so we got a long one that only partially addressed your comment directly.
Mainly, my comment was intended to provide information to the discussion, not to contentiously take issue with the entirety of your comment.
lurker
@Brachiator: @wjca: if memory serves, my parents’ dog would bark at the pool when waves from any quake started, even something in the low 3s if it was close enough. YMMV.
PAM Dirac
@David_C:
Yeah, I worked for a Federal agency that helped academic, pharma, and other government programs discover drugs. The LAST people I would want guiding a drug discovery program are the academics. A significant percentage of the big shots are perfect examples of people who are very smart in one area thinking they are very smart in all areas, and GMP/GLP is only a small part of it. It would be a long rant to go through all the serious structural problems in academic bioscience but I’ll just say that there is no shortage of sweeping serious misconduct under the rug. In my experience it is also true that the academic institutions are the most aggressive and unreasonable when it comes to patenting. Because of Bayh-Dole they have almost full control over how they license their patents and I have never heard of any institution that takes less money in exchange for limits on price. These days the dollar values of these deals is rarely mentioned, but here’s a press release from 2005 where Emory announces a payment of over half a Billion dollars from Gilead for the drug emtricitabine. It is probably fair to say that the development of the drug was heavily subsidized by tax payer dollars, but the recipient of the subsidy wasn’t the drug company, it was Emory University. The notion that drug companies get academically developed drugs for free is hogwash on many levels. Usually the most informed and substantial discussion on these matters can be found at In the Pipeline.
Barbara
@Brachiator: It’s a policy that was enacted by Congress many years ago. The Trump administration issued final rules to implement it, and Florida requested approval shortly thereafter — like more than three years ago, before Biden was elected.
So the policy is congressional, and the FDA is doing what Congress directed. The policy is misguided. Congress might as well have introduced the law by saying that “Having found that we as an institution are too broken to meet the needs of our own people, we hereby allow states to align themselves with our good ally Canada, which actually tries to protect its citizens from the exorbitant demands of drug manufacturers.”
As a technical matter, what would need to happen to protect safety of the drug supply will likely eat up most of the contemplated savings.
Martin
@Brachiator: Drug pricing is negotiated per nation in the EU, but there’s a lot of information and best practice sharing taking place. One thing the EU does pretty well is value based pricing – the ceiling for a drug is based on the clinical therapeutic value in terms of life extension, or quality of life (returning a person to the workforce has value to the state), as well as opportunity costs. If there’s a cheaper way to get the same clinical value, then that becomes the ceiling for your drug.
The VA does this to my knowledge (again, they employ their own clinicians – people really don’t appreciate how much better the VA is than almost all other health providers in the US) but I don’t think most other negotiators in the US does – at least based on conversations with my family, who included C-level Blue Cross/Blue Shield executives/board members. Not that they don’t necessarily want to, but they don’t have the ability to say no, and the drug companies know this. By comparison, the drug companies know exactly what happens if the VA says no, because their formulary trickles down pretty much everywhere.
See, if states negotiate in isolation, that probably doesn’t change a whole lot. But if they can negotiate collectively then things pretty rapidly converge to a federal system, with there being two basic coalitions – one including women’s health and gender therapy and one that doesn’t. The EU doesn’t have this kind of system, but they do share the underlying data, so small nations don’t need to offer up their own therapeutic value, and they can see what prices other nations are paying. It’s a more open system than the US, even if it’s not centralized. Plus, each nation still gets to set their own rules, so they can still say ‘no’. See why CA mandated that pharmacies carry the state insulin – because the market would simply have removed the drug from availability otherwise, but CA being sovereign can put that law down. US insurers can’t do that, so their ability to negotiate is really constrained.
The states are really just negotiating for their Medicaid systems and some smaller state programs, which in a lot of states (like Florida!) are pretty fucking small, because the states do everything to make sure they programs don’t function. So their ability to negotiate is even worse than you might otherwise think.
Brachiator
@lurker:
I appreciate the clarification. I also note that you have laid out the Republican hypocrisy very well here. Very well said.
I think that DeSantis and Trump understand how to come across as authoritarian populists. Trump of course plays the game better.
They are willing to violate right wing dogma to get conservative voters on their side. But they rarely deliver on what they promise.
Still, on the surface, the Florida proposal offers more than conservatives ever have before with respect to prescription drug prices.
wjca
I’m recalling a quake (late 70s or early 80s maybe?) when I was on the 10th floor of a San Francisco office building. The non-Californians either dove under their desks (essentially useless if it had been serious) or ran to look out the windows (damn stupid; it was the days when windows would pop out if the building flexed enough, taking those who were too close out, too).
Us native Californians mostly wandered casually towards the elevator bank (the most structurally robust part of the building) while saying “So what do you think — 5.3 or maybe 5.4?” Turned out to be 5.4, and a few hundred miles south east of us.
EDT I should probably note that, in anything resembling a hurricane, I would totally freak out. And a tornado would be worse. It’s all in what you’re used to.
Martin
@bbleh: What’s the point of even having a government if you collectively decide that not only doesn’t it work, but it can’t work. If your local eatery is just dumping McNuggets on a plate and bringing it to you, then shut the place down and just go to McDonalds.
If the US were a small country, or were dominated by foreign drug makers, then delegating to a larger nation would make some sense. But it’s the opposite. Canada should be importing from the US, because the US is in the superior position to negotiate. You have to fix that. You can’t just ignore it and delegate to some other nation.
Additionally, that’s the whole foundation of this country – that we are self-deterministic. The people elect the government to act on our behalf. We don’t elect Canada’s government, and they aren’t accountable to us. We should object to this on those terms alone. Sure, use Canadas pricing as leverage, but don’t outsource it.
eclare
@wjca:
Yeah, where I live tornado warnings don’t bother me. In an earthquake, I would be a desk diver.
PAM Dirac
@Martin:
Yikes. I read through that paper and I would be VERY hesitant to draw any broad conclusions. It looks like they did a name/topic search for the list of drugs, looked at the paper for funding info and then looked up the amount of funding through the NIH web site. A lot of work and maybe some interesting things to think about, but I suspect it is mostly about what academic researchers think will bring them funding rather that any connection to drug development and use. The vast majority of papers published have nothing to do with development decisions, approval decisions, or clinical use. And there is increasing discussion of a “reproducibility crisis” because the data in over half the papers checked can’t be reproduced. To assign the cost of any and all research that uses a particular drug as a benefit to the company that owns it is a pretty dubious assumption.
BTW, I’m not sure why you say “According to the NIH” since all the authors of this study are from Bentley University, Waltham, Massachusetts
Brachiator
@wjca:
It’s not just the value on the R scale. It’s about the depth or shallowness of the quake, location, quality of the soil, direction of motion, etc.
Quakes below 4 usually are no big deal. But I have been in moderate quakes that seriously damaged an older apartment building. I would love to be in a modern building with earthquake related improvements or one that has been seriously retrofitted.
bbleh
@Barbara: @Martin: oh I don’t disagree with either of you! The US — mostly via our political institutions, but also because of our fragmented healthcare system — is failing miserably at ensuring that pharmaceuticals are available to its people at cost-effective prices, and … we shouldn’t be! And there are different types of fixes, all evident and time-tested in other large industrialized countries!
We ARE taking some steps in the right direction — some generally implemented and others with growing support &/or some degree of implementation sub rosa. But there is an absolutely gigantic amount of money involved, and that means an awful lot of highly motivated and utterly self-interested snouts wriggling to suck out of the trough. Steering that kind of system is a Herculean task at best.
Of course, Trump would solve the whole problem by just Getting Everyone In A Room and Knocking Some Heads Together and … [sigh].
Cathie from Canada
@Thor Heyerdahl: And wouldn’t Trudeau love to get into a pissing contest with Desantis! We have our own Desantis clone here, the Conservative leader Pierre Poilievre, and Trudeau regularly mops the floor with him.
David Anderson
@Brachiator: Not objecting, just don’t think it is is going to do much.
Sister Machine Gun of Quiet Harmony
@bbleh: Insurance companies, Medicare, and VA have formularies that are in part based on cost effectiveness studies. They do constrain some of the costs. However, there are always patients who demand something different and physicians who are happy to prescribe something obscenely expensive.
bbleh
@Sister Machine Gun of Quiet Harmony: yeah it’s become more accepted to talk about it as “a factor” or “from an academic perspective,” or just to quietly implement it and tap-dance around it if and when necessary. There’s even an informal ICER standard. We just aren’t to the point where our healthcare-payer decision-makers say “we demand this.”
Brachiator
A few tidbits about Florida. I would think that retirees would like to see lower prescription drug prices. Note that I am not saying that DeSantis will deliver or that his is the best proposal.
Population 2023
22,610,726
Retirees
By Total: California has the highest number of seniors in the U.S. with a total of 5,148,448 residents ages 65 and older. But that is likely because California also has the highest population out of the states. Second in line is Florida, with a total number of 3,926,889 seniors.
17 percent of Florida population are seniors
Martin
@Brachiator: That would only help seniors on Medicaid. Florida has no bargaining power on behalf of Medicare which is fully federal. CAs interest in manufacturing it’s own drugs is because it spends so much on MediCal – about 5x what Florida does, because CA expanded Medicaid to cover undocumented residents on state tax dollars, while Florida does pretty close to the minimum – they have not yet accepted Medicaid Expansion. That’s why the savings to Florida are so small – $150M. I mean, Rick Scott alone defrauded Medicare by more than a billion – $150M isn’t very much because of how few people this would actually impact.
Brachiator
@Martin:
What a mess.
More numbers
Florida Medicaid enrollment: 4,752,201
There were about 566,000 Medicare-Medicaid enrollees in Florida and about 9 million nationally. Medicare-Medicaid enrollees represented 3% of the State’s population, compared to 3% for the United States.
The independent source for health policy research, polling, and news. 67% of non-elderly. Medicaid enrollees in FL are people of color.
more than 7 million people in the United States have lost Medicaid because of a process called “Medicaid Unwinding” — or “disenrollment.” In Florida, more than 700,000 people have been dropped. Nearly half lost their Medicaid for procedural reasons, like missing paperwork or not responding to renewal requests.