A shy woman, seldom prone to displays of political exasperation, Jane Hanlon spread copies of her prescription bills out before her and let the figures do the talking. Until recently, the 71-year-old hairdresser paid $95 a month at her neighborhood pharmacy for the tamoxifen that has kept her breast cancer in check for eight years.
Now Hanlon gets her tamoxifen from Canada--for $125 a year.
"And that includes shipping," said Hanlon, of nearby Williamstown, Mass. She paused to collect her thoughts, then added: "The way drugs are marketed in this country, well, somebody's making a lot of money off us senior citizens. If Canada can do this, why can't we?"
Hanlon and thousands of elderly residents of New England border states aren't sitting around waiting for answers from politicians who made prescription drugs for seniors a centerpiece of the election season.
By bus, by car, by foot and by fax machine, seniors have set up an expanding underground pipeline to secure medication from Canada, where drugs often sell for a fraction of what U.S. consumers pay. Increasingly, U.S. doctors have become allies.
Crossing the Canadian border to buy up to a six-months' supply of prescription drugs is within the laws of both countries. A U.S. citizen must visit a Canadian doctor to obtain a valid prescription. Alternatively, some U.S. doctors have "border licenses" to prescribe in both countries. But the spinoff method of ordering medication from Canada by fax is in a nether world: not quite legal, but also not entirely illegal.
Senior citizens are such a vulnerable population that no legislature has moved to ban the Canadian prescription drug purchasing efforts. But some organizers of bus trips say they fear lawmakers may bow to the clout of the prescription drug industry by attempting to halt the trend.
On an informal basis, foreign drug-buying is hardly new. For years, people from California and other border states have slipped into Mexico to buy medication. But organized prescription shopping excursions--"drug runs," as some senior citizens here playfully call the trips--have turned the phenomenon into a mass experience.
Chartered bus trips that began about a year ago in Vermont have inspired imitation in Western border states, even turning into campaign events in two U.S. Senate races this fall. Minnesota Democrat Mark Dayton took a busload of elderly drug buyers to Canada and won. Brian Schweitzer of Montana, also a Democrat, did the same but lost. After Rep. Bernie Sanders (I-Vt.) became the first member of Congress to host a bus trip last year, several of his colleagues followed suit.
As if they were three nations negotiating a trade treaty, Maine, New Hampshire and Vermont are forming a buying co-op to bring cheaper pharmaceuticals to their elderly residents. Some doctors in U.S. border communities have obtained licenses allowing them to prescribe directly to Canadian pharmacies. In towns such as Calais, Maine, patients simply stroll across a bridge to New Brunswick to buy medication.
Recently, a health care group here found a way around the ordeal of long bus rides to visit first a doctor, then a pharmacy in Canada. Using a prescription-like template, a handful of Vermont doctors faxes drug orders for patients to a Canadian pharmacy. The drugs are then shipped to the ordering doctor's office, where patients pick up their supply. Even with FedEx charges, the drugs usually cost U.S. patients a sliver of what they used to pay.
The drugs are cheaper in Canada because that country's system of socialized medicine tightly controls pharmaceutical costs. U.S. drug prices also are higher because of costly advertising campaigns, government lobbying and research and development expenses. Another factor is the favorable exchange rate for U.S. dollars in Canada that makes items less expensive there.
Same Drugs, Same Packaging
Drugs purchased by U.S. citizens in Canada generally are manufactured in the same plants in Puerto Rico as drugs sold in this country. Often the packaging is identical. Doctors and other medical experts say the Canadian prescription drug market is more closely supervised than its counterpart in Mexico, where pharmaceuticals can be purchased without visiting a local doctor--and sometimes without a genuine prescription.
Seniors, many on fixed incomes, celebrate the savings of shopping in Canada but lament a U.S. prescription marketplace that sends them--and their dollars--out of the country. They are well aware of the political message inherent in this elderly exodus.
"I'd have to say it's pretty shameful," said 71-year-old Barbara Gordon of Grand Isle, Vt. Gordon and her husband, who are retired dairy farmers, ride the bus every few months to Quebec for medication.
Not surprisingly, the U.S. prescription drug industry condemns the trend. In full-page newspaper ads, industry groups warn that pharmaceuticals purchased in foreign countries lack the tight controls of the U.S. Food and Drug Administration. Lower drug prices in this country would mean less of the research and development that produces important new medication, the industry contends. Drug manufacturers say that their extensive advertising in this country helps to inform citizens.
Industry officials urge Medicare reform to provide increased prescription drug coverage for seniors.
"We don't think that U.S. senior citizens should have to go to Canada to get prescription drugs," said Dan Zielinski, a spokesman for Citizens for Better Medicare, a Washington-based consortium of pharmaceutical groups. "What we have said and continue to say is that seniors who need help affording their prescription drugs would be best helped with health insurance coverage that has prescription drug benefits."
Sanders, for one, scoffs at the industry's position.
"It is an absolute outrage that the pharmaceutical industry, which last year made $27 billion in profits, continues to charge the people of Vermont and this country by far the highest prices in the world for prescription drugs," he said. "Until we have real prescription drug reform in this country, I think you're going to see huge numbers of people going over the border."
The number of citizens who buy drugs in Canada is unknown. Along with the dozens of groups that take thousands of people, many people make the journey on their own.
Numbering just 12% of the U.S. population, senior citizens make 30% of drug expenditures. Americans 65 and older particularly feel the pinch because Medicare, the federal health insurance program for the elderly and disabled, does not include prescription coverage. Many older Americans balk at costly secondary insurance, and even those who can afford policies find that managed care plans are reducing drug benefits.
Seniors are also living longer, and the chronic conditions that increase with age require multiple medications. Many seniors make do by taking fewer drugs than prescribed or by taking drugs less frequently than prescribed.
"I see too many of my patients who are either not taking their medications or not taking them correctly," said Dr. Michael Welther, a family practitioner in Arlington, Vt. That realization puts doctors in a compromising position, said Welther, who six months ago was among about 100 physicians in the United Health Alliance here who helped the nonprofit health agency launch a Web site to assist doctors in obtaining drugs from Canada for patients.
The alliance's Web site includes a form resembling a prescription, which a U.S. doctor can fax to an Ontario pharmacy along with the patient's credit card number. The drugs are shipped to the doctor's office, which turns physicians into middlemen--a role Welther said he is willing to assume.
"I wasn't trained to be a druggist, but I was trained to be a patient advocate," he said.
The novel approach was developed after alliance president Elizabeth Wennar--eager to see what her clients were going through--took a 12-hour bus trip to Canada sponsored by a Vermont state agency. On a beastly hot day, Wennar said, "there were people crippled with arthritis, people with canes, in wheelchairs. I watched them, they had to be carried on and off the bus."
The seniors were "so proud of themselves because they had figured out how to get their medication at an affordable price," said Wennar, a public health advocate.
Her own reaction was much different.
"After the trip, I had to sit in my car and contain myself because I was so angry," she said. "I thought, it's horrific, it's embarrassing, it's obscene. How can the drugs possibly be that much cheaper?"
Vermont Gov. Howard Dean, a physician and a Democrat, supports the alliance's maverick approach, and Wennar said inquiries pour in from physicians around the U.S. seeking to replicate the template order form.
Effort to Subsidize Fails in Court
Seeking to assist elderly and poor residents, legislators in neighboring Maine in May passed the nation's most sweeping measure to subsidize prescription purchases for underinsured residents. But after a legal challenge by the drug industry, a state judge struck down most of the bill in October.
John Marvin, Maine's regional director for the National Council on Senior Citizens, called the action a setback for the 325,000 residents in Maine--about a quarter of the population--who are uninsured. Pending new legislation, Marvin said poor and elderly Mainers would be more dependent than ever on treks to Canada.
After working for 44 years at Maine's Hathaway shirt factory, Viola Quirion, 74, of Waterville said she needed to make bus trips to Canada every three months to buy Prilosec, a drug that helps her stomach troubles, and Relofen, for her arthritis. Canadian pharmacists will fill up to a six months' supply, but on her monthly fixed income of about $1,000, Quirion can afford only three months' worth of medication. Buying the drugs across the border cuts her yearly U.S. prescription bill of $2,000 to $3,000 by more than half, Quirion said.
In Calais, Maine, across the St. Croix River from St. Stephen's in the Canadian province of New Brunswick, family practitioner Laurie Churchill said two to three patients a day come to her from other parts of the state to take advantage of Churchill's border-area license, enabling her to prescribe to Canadian pharmacies.
At the Guardian Drug Centre in St. Stephen's, pharmacist Valerie MacDonald said she cringes when she hears her U.S. clients discussing the sacrifices they make to afford drugs.
"Making the choice between food and medication," she said. "That's the sad thing."
Another pharmacy in St. Stephen's, the Super Store, eases that dilemma by serving U.S. seniors complimentary sandwiches while they wait for prescriptions.
When the organized bus trips to Canada started a little more than a year ago, they might have been seen as a political ploy or a public relations campaign, said Stephen Schondelmayer, professor of pharmaceutical economics at the University of Minnesota.
"But now there are people who depend on this method of buying prescription medicine. It's a signal from the market that something's not working," he said. "This is an attempt for the market to work, and the industry is not responding to market pressures. They're kind of continuing their own agenda."
Zielinski, of Citizens for Better Medicare, said the trade-off for lower drug prices "is more government controls on medicine." With far less drug research and development in Canada, he said, low prices there have a cost of their own: fewer new life-enhancing products.
He agreed that Medicare reform is far away. For elderly Americans who need affordable medication now, Zielinski said, "I wish I had the answer."
Retired aeronautical engineer Gene Cairns blames the drug industry, but he also takes aim at politicians who don't "give a damn one way or the other."
Cairns, 72, offered a pill-by-pill price breakdown of the drugs he gets by mail from Canada through the alliance. For his cholesterol, Cairns takes Pravacol, at $2.71 per pill from his local pharmacy. In Canada, Cairns pays 82 cents per pill.
"Same bottle, same label, same packaging," he said. "I can't find any fault in buying from Canada. Hell, this administration and the one before it pushed NAFTA [North American Free Trade Agreement]. If this isn't free trade, I don't know what it is."
Despite the ingenuity involved, Schondelmayer of the University of Minnesota notes, the cross-border drug purchases are largely unregulated and could be in jeopardy if there's a government crackdown.
In the meantime, Gordon, the retired dairy farmer, depends on regular trips north.
She and her husband planned for what they thought would be a comfortable retirement. "When we made our money, everything was cheaper. We had no idea drugs would cost so much."
With her prescriptions ready for renewal, Gordon said that if she couldn't find a bus trip, she'd have to hire someone to take her across the border.
"A 71-year-old woman who has to go to another country to get her medication," Gordon mused. "Well, it's wonderful that we can do this. But sad that we have to."
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Here is a sample of price differences between Canada and the United States for several common prescription drugs.
Source: United Health Alliance in Bennington, Vt., http://www.unitedhealthalliance.com