I suffered when the lilacs bloomed about three weeks ago. After more than six decades of being the only allergic person in an allergic family (my father, of blessed memory, used to say with some perverse pride that he was allergic to himself) I developed pollen allergies a few years ago, along with sudden empathy for people with allergies.
NOW I know what people with allergies are talking about, and now I understand that kind of suffering. When I get hit, I get it all – the runny nose, the exploding head, the aching, and the cough, which for me almost always blooms into a full-blown cough variant asthma attack – so I cough instead of wheeze but can’t sleep because of the cough. Can’t sleep. Can’t talk. Can’t work. Can’t think.
But after a couple of years of this, and a little pharmacology knowledge, I’ve figured out what doesn’t work. (Mandatory disclaimer. If you get sick, call your family doctor and do it early. Poorly controlled asthma can kill you.) A couple of aspirins. A steroid nasal inhaler. Diphenhydramine aka Benadryl at night, short acting pseudoephedrine aka Sudafed in the morning and at noon. Sometimes a little benzonatate. After a couple of days of intense denial, a steroid and albuterol or long-acting beta agonist inhaler, and, more often than not, a couple of days of prednisone.
Nothing that complicated, and better yet, almost nothing that expensive. (Okay the inhalers have gotten ungodly expensive. But I have a couple of old ones, and I don’t use them very much so they each last for years.)
This year, though, I ran out of steroid nasal inhaler early, so went to I buy new ones.
The good news is that steroid nasal inhalers are generic in the U.S., so I figured they wouldn’t be too expensive. As I’ve mentioned before in this column, I pay for all my own health care up to an $8,000 deductible, so I watch prices like a hawk.
What does Flonase cost? $16 at Target. $15 at Walgreens. $26 at CVS but for twice as many sprays. But there is a generic that costs $9.69 at Target and $9.18 at Walmart and $20 at Walgreens. I pushed hard and found five bottles for $25 or about $5 a bottle on Amazon and each bottle has 144 sprays, or twice as many as most other generics. Which means it likely costs $1 to $2 to make. (Interestingly, it costs $40 in Canada, where it is still prescription, so thank you FDA for doing at least one thing right and making it generic here.)
But I want to go back to the likely $1-to-$2 to-make factoid. For 144 sprays, that’s about a penny a spray, which makes it almost cheap as water. I’m guessing most of the cost is actually in the bottle and the bottling process, because most generic medications are incredibly inexpensive and cheaper than water to make. There are a whole lot of tried-and-true medications –antibiotics, blood pressure pills, medications for diabetes and arthritis –likely ninety to ninety-five percent of the medications people actually need to take –that are cheaper than water to make, and should be what most of us use, if we can find them. Find the lowest cost of Xarelto (and other blood thinner medications) when you use edrugsearch.com.
But let’s pay attention to that last phrase, the if-you-can-find-them piece. Because you can’t find many generic medications at all, even though they are cheaper than water to make.
Why should that be? For two reasons, both painful, and both reasons illustrate how crazy medicine and health care is today.
First, it makes no financial sense for any for-profit company to make cheap generics in the health care market that is for profit. If you are a drug company and must pay for a building and machines and the chemicals out of which medications are made, and you can make money selling more expensive medications, it makes no sense to make inexpensive medications. The time and hassle of manufacturing, the regulatory hassles, the liability that haunts all health care, all of that does not produce a significant profit if you make medicines that are cheaper than water. Generic medicines are so cheap to make that they can’t be sold for very much at all, so no one wants to make them.
It’s like the old joke about losing money on each one and trying to make it up in volume. You make no money on each pill when you make generic medications, and no money doesn’t add up to some money when you produce a lot of what doesn’t generate any margin.
But people benefit from inexpensive generic medications. How cool it would be if most medicines cost next to nothing, and if you could walk out of a doctor’s office with all the medicine you need for three months and didn’t even have to stop at the pharmacy. Good for you. Not so good for CVS and Walgreens, however. Remember that in the health care market we have, no one in charge of doing what is good for everybody. But individuals with something to sell are in charge of generating profits for themselves and their shareholders.
The second reason there aren’t lots of cheap generics around is that some unscrupulous drug companies go around and buy up generic drug companies and then jack up the prices of their products when no one is making a competitive product. (Please remember that not all drug companies are unscrupulous. But all are for-profit.)
There are a zillion stories about this happening. Diaprim, an antiparasitic drug made by a single manufacturer, which was taken over by a venture capital backed company named Turing Pharmaceuticals led by the infamous “pharma-bro” Martin Schkreli, who ended up in jail after a conviction for securities fraud, saw its price per pill increased from $13.50 per pill to $50 per pill. Cycloserine, a drug used to treat multidrug resistant tuberculous, a very scary disease indeed, increased in price from $500 for thirty pills to $10,800 after it was acquired by Rodelis Pharmaceuticals. Doxycycline, the mainstay of treating Lyme disease and a number of sexually transmitted diseases, went from $20 to $1,849 a bottle in 2014 – and I remember it as being far cheaper in the 1980s, maybe $3 to $5 a bottle, when we used to think of it as cheaper than water, back in the day before the generic manufacturing process got overwhelmed by the rapacious greed of pharmaceutical companies. 17-hydroxyprogersterone, a hormone used to prevent premature labor and synthesized in 1940, a compound that that wasn’t patented and could be compounded by any compounding pharmacy for $5 a dose, saw its price driven to $1,500 a dose by a pharmaceutical company that manipulated orphan drug process of the FDA.
So we have a situation in which generic medicine is amazingly inexpensive to make, but no one wants to make it, even though inexpensive generics are good for all of us. Which to me means government should make generics and give them away. Generic medication is an essential service, like police or fire protection, roads and sewers, and public schools (and primary health care, just saying).
Please don’t start calling this socialized medicine. I’m not saying we should nationalize all the drug companies or even limit their profits (although there is a strong argument to be made for Medicare and Medicaid to negotiate drug prices for their recipients.)
We don’t call fire protection socialized fire protection. Or sewers socialized sewers. People come together in government to provide essential services for one another. That’s how we create an equal enough society to make democracy function. That’s a good thing. Remembering what Churchill said, which is that democracy is the worst form of government, except for all the others.
Here’s the rub: health care that is for profit is for profit. It is not for people. It’s crazy to turn the health of the American public over to people with something to sell. We can do so much better than this.
Many thanks to my friend and colleague Nick Landevic, for reality testing these ideas and for finding most of the examples of drug companies jacking up prices of generic medications.
(Dr. Michael Fine is a former director of the Rhode Island Department of Health, a community healthcare advocate, and an author of novels, medical books, and short stories)