New Hampshire's Republican Gov. Chris Sununu and Democratic State Sen. Dan Feltes disagree on gun control, the minimum wage, paid family leave, and taxation.
But one thing they do agree on unequivocally is opening the border with Canada — a quick drive for many Granite Staters — for the import of cheaper prescription drugs.
"The people of New Hampshire are in some cases rationing prescription drugs. They're rationing insulin, and it has negative consequences obviously to their health," said Feltes, who sponsored a state bill in January that would open the door to drug imports, one that Sununu has since endorsed.
The bill is part of a package of legislation that aims to cut the cost of prescription drugs. Other measures include the creation of a drug affordability board to increase price transparency and the prohibition of insurance companies from changing drug coverage in the middle of a plan year.
Drug prices in New Hampshire increased 2 percent in 2018, according to a state Department of Insurance report. Major U.S. drugmakers also increased list prices on 250 drugs going into 2020.
The cost of drugs has become a visceral issue for New Hampshire voters, who are all too aware of the prices available just across the border. "In 2017, 22 percent of New Hampshire residents stopped taking medication as prescribed due to cost," Sununu testified before the Senate Commerce Committee last month. "That is wrong."
It was a rare bipartisan moment as Democratic presidential candidates flocked to New Hampshire for the first primary state, where they would make the case for their respective health care plans that range from creating a single-payer health care system effectively abolishing private health insurance to rebuilding and fine tuning the Affordable Care Act.
The question of drug prices has also loomed large at the national level. All of the major Democratic candidates support some form of federal price negotiation, and there is broad support for allowing drug imports as well, including from the candidates' biggest opponent: Donald Trump.
The Trump administration, which initially opposed drug imports, issued a rule change in December that, if finalized, will allow the practice on a state-by-state basis. The policy change lines up with local efforts, such as New Hampshire's, to pass import proposals themselves.
Gimmick or Cost-saver?
Despite the tangled politics of drug prices in the U.S., the supply side of the equation may prove the biggest stumbling block.
Canada's relatively small drug market faces persistent shortages, and drugmakers and government officials alike argue that imports would only make things worse.
"Not only are we too small of a market, Canada cannot increase its domestic pharmaceutical drug supply to meet U.S. demand," acting ambassador to the U.S. Kirsten Hillman said in a statement. "In fact, a September 2019 U.S. study predicts that even if a mere 40 percent of U.S. prescriptions were filled using Canadian sources, the Canadian drug supply would be exhausted in 118 days."
Canada has cheaper drugs for a reason, of course.Through its national health system, the government reserves the right not to purchase a drug if an oversight board deems the cost excessive. This creates a situation where drugmakers will often negotiate prices with the government for fear of losing out on the entire Canadian market.
In effect, the U.S. would like to take advantage of Canada's leverage over pharmaceutical companies, but it's possible that a huge influx of buyers would ratchet up costs anyway.
"I haven't seen very much support on the Canadian side for this," said Meredith Freed, a policy analyst for the Kaiser Family Foundation, which tracks the health care sector.
There is significant imbalance in the size of each market, Freed added: Canada consumes about 2 percent of the global drug supply, and the U.S. consumes about 44 percent.
The rule change passed under Trump would not create a free-for-all, however. States would have to submit importation plans to the Food and Drug Administration that explain how cost-savings would be achieved and ensure that the plans pose no additional risk to the public.
Certain drugs will also remain strictly banned, including expensive biological medications such as insulin and controlled substances such as opioids.
New Hampshire's new regulation is based on an existing law that's been around since the early 2000s that allowed pharmacies and wholesalers to import drugs, but no federal administration has approved a state import plan or offered any guidelines for compliance.
For a while, it looked like Trump would follow in that decade-long tradition. Indeed, Secretary of Health and Human Services Alex Azar had recently called drug imports a "gimmick" and echoed concerns that Canada did not have the capacity to meet U.S. demand.
"One of the main reasons is that Canada's drug market is simply too small to bring down prices here," Azar said in a 2018 speech. "They are a lovely neighbor to the north, but they're a small one. Canada simply doesn't have enough drugs to sell them to us for less money, and drug companies won't sell Canada or Europe more just to have them imported here."
One year later — and one year closer to an election — Azar is actively promoting the new policy and rolling out a pilot program in Florida, a major swing state.
Other states are following suit: Maine, Vermont, Florida, and Colorado have passed laws to prepare their own import plans, and legislation is pending in New Mexico as well.
One More Tool in the Tool Box
Some argue that drug imports remain a stop-gap measure that would not alter the powerful leverage that drug companies hold over insurers.
"The better answer is very simple and very easy: let Medicare negotiate drug prices," said Tim Faust, an author and advocate for Medicare for All. "That we prefer this insane, byzantine, export-import model tells you something about the political courage of our lawmakers."
Democratic candidates agree that Medicare should help negotiate prices down, but they disagree substantially on the scope of Medicare.
Under Bernie Sanders' plan, for example, a national health system would negotiate and set drug prices, and out-of-pocket costs would be capped at $200 per year or free for those below the federal poverty line.
Joe Biden and Pete Buttigieg have proposed creating a public option to compete with private insurers and ideally drive down prices, leaving Medicare to the seniors. Biden has also said he would create tax penalties for drugmakers that hiked prices above the inflation rate.
Andrew Yang and Elizabeth Warren have proposed creating a government-run pharmaceutical manufacturer that would compete with private suppliers.
Sanders, Warren, and Yang have said they would use executive actions to clamp down on excessive drug prices and speed up the approval of generic drugs.
Many of these schemes have been gestating for years, but none have broken through the impasse of Congress. One bill passed the House in December that would have forced drugmakers to negotiate with the federal government on the price of 50 different drugs, but it stalled in the Senate.
The lack of progress on more expansive reforms at the federal level, Freed said, has a lot to do with why drug imports have become a go-to bipartisan solution at the state level. Yet local lawmakers don't see drug imports as a silver bullet, but rather the beginning of a broader push to make health care affordable.
"It's something that the public supports and has thought about for a while, but it's just one tool in the toolbox," Feltes said.
