July 14, 2000 -- It's 7:45 on a steamy Friday morning in June, and the commuter parking lot on the outskirts of Montpelier, Vermont's capital city, is filling up with people in need of drugs.
Ramona and Peter Christensen, dairy farmers from East Montpelier, approach the crowd around the two 15-passenger buses that will take them on the two-and-a-half-hour ride across the border to Montreal. "I'm a little nervous with all this money on me," says Ramona, 45, as she flashes a fat wad of cash. "Are the drug czars here yet?"
The Christensens aren't here to score marijuana or cocaine; they're after drugs for Ramona's high blood pressure, diabetes, and heart disease. And they're not alone. Drawn by prices that can be a fraction of the cost in this country, more and more Americans are crossing the border into Canada or Mexico to buy prescription drugs they cannot afford to buy at home. Indeed, the high cost of medicine in the United States is emerging as a leading political issue of the new decade: Congressional and presidential candidates alike are promising to somehow make pharmaceutical drugs affordable here, in one of the wealthiest nations of the world.
A Huge Difference in Price
Because other nations have price controls on drugs, savings across the border can be dramatic: A one-year supply of tamoxifen, a cancer suppressant widely prescribed for survivors of breast cancer, costs about $1,400 in the United States but just $125 in Canada. Ramona Christensen's 30-day supply of Lipitor, a drug used to lower cholesterol, costs $144 here and $85 in Canada.
While debate rages in Congress on how to lower U.S. drug costs, seniors and other people in need of affordable medications are moving ahead with their own underground solution.
At the parking lot in Montpelier, the "drug czars" -- three organizers from the Central Vermont Council on Aging (CVCOA) -- pull up in a minivan and begin transferring coolers full of sandwiches and sodas into the waiting buses. The three began making drug runs to Canada in April after Vermont's U.S. Congressman, Bernie Sanders, led several well-publicized trips there to help people buy affordable prescription medications. Similar trips have been organized from several other border states, inspired by the huge price differences. Overall, seniors in Vermont pay an average 81% more than Canadians for the 10 most widely used prescription drugs, according to a new Congressional Research Service study.
As the green hills of Vermont roll by their windows, the 17 people on the bus pull out their prescriptions and compare notes. Delores Remington, 66, a former newspaper clerk, needs five medications, which would cost $825 in the United States; she went on the last trip to Canada and bought them all for $475. Ramona Christensen has 35 pages listing the prescriptions she needs for the next 14 months. The total, if purchased here: more than $20,000.
Christensen was covered by Medicaid (which provides prescription drugs) until May 31, when her benefits were cut off after government social workers disqualified her because she'd made too much money on her farm. Now, she says, her family is trying to live on an income of $1,000 a month. To pay for her medications, Ramona and her husband have sold 11 of their 85 dairy cows. At $1,200 per cow, they figure they'll have enough to pay for a year's worth of medicines.
Taking Half-Doses to Save Money
Cliff Bates, a 60-year-old retired paper mill worker, pays about $300 per month for five medications he needs to treat knee problems, high cholesterol, and high blood pressure, and hopes to save quite a bit. He says he's tried to save money by splitting his pills and taking half a dose, but that "doesn't work so good -- I got dizzy."
Technically, the Food and Drug Administration (FDA) prohibits the importation of prescription drugs from other countries. But the Canadian trips take advantage of an FDA loophole that allows individuals to import a limited supply of approved drugs for personal use. Still, the agency has broad enforcement discretion, and as the bus approaches the border, there are jokes about what reasons to give for going to Canada. The "drug czars" opt for the truth and explain the mission to sympathetic border guards. The guards wave them through, noting that plenty of people are doing the same thing on their own.
While the FDA is not currently trying to prevent drug-buying in Canada, that could change. In an effort to head off an FDA crackdown and to draw attention to the huge price differences, the House of Representatives on July 10 overwhelmingly approved a bill barring the agency from enforcing the general ban on drug reimportation.
'My Job Is to Take Care of Patients'
It's noon when the group arrives in Montreal. They troop up a winding stairway to the packed waiting room of a health clinic where the Americans fill out forms, see a doctor (for a $24 fee), and present their American prescriptions. Nii T. Quou, MD, the clinic's medical director, says he's been warned about possible legal liability from seeing American patients, but he welcomes them all nonetheless. "I'm a physician," he says simply, "and my job is to take care of patients."
The Vermont organizers hand out the sandwiches and sodas, then begin ferrying batches of people to a family-run pharmacy nearby. The pharmacist and his family welcome the group with pastries in a homey back room where the travelers rest and wait for their precious supplies.
Drug Companies Offer a Caution
Drugmakers have been angered and embarrassed by the publicity the bus trips have drawn. They warn consumers against crossing the border for medications, saying they can never be sure what they're getting, even when drug labels are the same as in the United States. The companies also say higher U.S. prices are justified because of the high cost of research that has produced so many wonder drugs. They've been fighting back with television ads and a web site to make the case that the U.S. health care system is preferable to Canada's.
The industry has also worked hard to fend off attempts by Congress and some states to impose price controls on prescription drugs. Indeed, the United States is the only industrialized country without some form of controls on drug prices. In Canada, provincial authorities negotiate bulk discounts with pharmaceutical companies and establish allowable prices for most prescriptions. The Mexican government also sets price ceilings for medicines.
Drug prices in America vary greatly depending on who pays the bills. Insurers and employers pay most prescription costs, but this is changing as managed care plans impose caps on prescription reimbursements. Some companies are putting expensive drugs off- limits or reducing drug benefits, requiring workers to make larger copayments. And people who rely on Medicare, which serves senior citizens, are on their own, since Medicare does not currently pay for any outpatient medications.
The growing outcry over high drug costs has forced both political parties to seek out ways to provide prescription coverage to seniors on Medicare. Republicans want to offer government subsidies to encourage private insurance companies to offer drug policies to the elderly. The Democrats would increase Medicare payments to hospitals and other health care providers, making a drug benefit part of the program.
But it is state governments, especially those that border Canada, that are taking the lead on establishing price controls. In May, a law was passed in Maine -- over industry objections -- that created a commission with the power to negotiate drug prices for uninsured Maine residents and to impose price limits in 2003 if drug companies don't lower costs.
In Vermont, a similar bill would have imposed price caps and taken other steps to make medications affordable. It was defeated after what Vermont House Speaker Michael Obuchowski called "the most intensive lobbying effort" that he'd seen in 28 years, mounted by drug companies and the Pharmaceutical Research and Manufacturers of America (PhRMA), the industry's trade organization.
Sanders, the Vermont Congressman who led drug-buying trips to Canada, says the issue of high prescription drug prices arouses more anger than any he has encountered in his career. Last year, he introduced a bill that would allow American distributors and pharmacists to re-import prescription drugs into the United States from Mexico and Canada at the lower prices offered there -- as long as the drugs meet strict safety standards and are approved by the FDA. "There is simply no reason why Americans should pay up to 10 times more than people in other countries for the exact same drug," Sanders argues. Similar legislation was introduced this year in the Senate by Vermont's Republican Senator, Jim Jeffords.
Who Should Pay for Costs of Drug Research?
The pharmaceutical industry is fighting hard against efforts to allow drug importation and to control domestic prices. The industry argues that drug prices are artificially low in other countries and that imposing controls here would limit the resources drug companies could put into the expensive research required to develop new drugs. "We totally oppose any form of price controls because it discourages innovation and investment in research and development," says Meredith Art, a spokesperson for PhRMA. "The solution to high prescription drug prices is to add an outpatient drug benefit to Medicare."
But the political jockeying over drug prices is not what concerns the bus riders; they're after the drugs they need to live. They know they can get those drugs cheaply in Canada, and they cannot in the United States. As the van makes the long trip back to Vermont, people compare notes on savings. Ramona Christensen saved about $1,600 on 11 prescriptions. Joe Arnell, a former corrections officer who is "almost 65," saved $256 on seven prescriptions, mostly heart medications. Everyone says they would return to Canada if necessary, though Christensen is apprehensive about taking the bus during the icy winter months. Delores Remington, the former newspaper employee, appreciates the bus trip, but is saddened by the need to make the trek.
"We shouldn't have to get on a bus and go to another country to buy the medications we need," she says. "We ought to be able to do that in our own home town."
Curtis Ingham Koren writes for national magazines about health, education, business, and travel from her home in Vermont.