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A Prescription For Cheaper EpiPens

an EpiPen resting on a red leather seat next to a bag's strap
photo by Vu Nguyen

Dozens of people die in this country every year as a result of bee stings alone, and the total number of deaths from anaphylactic shock easily numbers in the hundreds, although statistics are surprisingly vague.

Fortunately, however, it is clear that nobody dies from exposure to crocodile tears. Amid the howls of outrage over the pricing of life-saving EpiPens, that fact is at least small comfort.

Mylan Pharmaceuticals holds a monopoly on epinephrine auto-injectors, popularly known as EpiPens. The devices deliver a premeasured dose of epinephrine, or adrenaline, which can buy life-saving time for a patient suffering anaphylactic shock. When properly administered, epinephrine can open airways and stabilize blood pressure while a patient is transported to a hospital. For severe allergic reactions, an EpiPen can truly make the difference between life and death.

Bee stings are a serious matter in the mountains of the Northeast, where millions of people – including me – take vacations every summer. About a decade ago, a teenager who worked with one of my daughters died after being stung in a remote corner of Pennsylvania. She was not carrying her own auto-injector, and by the time she could be rushed to a hospital in Binghamton, New York, it was too late. We can’t know for sure whether the medical device would have saved her life, but it could have given her a fighting chance.

Unfortunately, like many American pharmaceuticals, EpiPens are not cheap. As Modern Healthcare reported in March, a two-pack of EpiPens costs most customers $535, less a $100 coupon; uninsured customers pay as much as $574, even after the discount card. The product’s retail price topped $600 for a two-pack this May.

Customers can’t space out purchases by buying one auto-injector at a time, because the company has phased out single packs in recent years, purportedly under the theory that a patient may often require a secondary dose. Customers can’t simply hang on to their injectors indefinitely once purchased, either. EpiPens’ shelf life is generally no more than a year, so even if they are not used, they need to be regularly replaced.

Mylan does offer an assistance program, in addition to the discount cards, which provides free EpiPens to customers below a certain income threshold. But this has not stopped Americans from noticing their neighbors get a much better deal.

In Canada today you can buy a single brand-name EpiPen for around US$100 – something you can’t do in the States at any price – and a two-pack will set you back about US$200. That’s one-third the brand-name price at home and still substantially cheaper than the generic alternative that Mylan announced yesterday. In the United Kingdom, a two-pack will go for 90 British pounds, or about $135. Many Australians’ EpiPens are government-subsidized, but even those who don’t qualify can buy a twin pack for around $100. Hence the outrage from Americans – and, quite loudly, from American politicians.

For the most part, these are the same politicians – in both parties – who have created the safe space for pharmaceutical companies to charge us the world’s highest prices for life-saving medications by prohibiting us from buying and bringing in cheaper drugs from Canada, Britain and elsewhere. Unlike so much else in the morass of the American health care system, we know how to cure excessive drug prices, or at least how to alleviate the symptoms. Our lawmakers just refuse to write the prescription.

Maintaining the rules against “re-importation” was part of the bargain when the Medicare Part D drug benefit was enacted in 2003 under President George W. Bush. It was again part of a deal that the Obama administration and congressional Democrats reached to pass the Affordable Care Act in 2010.

In 2012 members of both parties teamed up to block a bipartisan compromise reached by Sen. Charles Grassley, R-Iowa, and then-Sen. Max Baucus, D-Mont., which would have allowed Americans to buy prescription pharmaceuticals from Canada. The measure needed 60 Senate votes to pass, but only received 43. Democrats, who then controlled the chamber, split 26-24 in favor and were joined by independent Bernie Sanders, while Republicans went 16-29 against.

Leaders in both parties – Harry Reid for the Democrats and Mitch McConnell for the Republicans – voted against the importation measure, although probably for very different reasons. Reid (along with his expected successor, New York’s Charles Schumer) was upholding the pact the Democrats made with the drug industry to get Obamacare passed. McConnell and many of his fellow Republicans probably saw little point in helping the Democrats out of the ditch they dug for themselves.

After the 2012 measure failed, at least one state government attempted to take re-importation into its own hands: Maine passed a law in 2013 purportedly allowing residents to purchase medication from designated mail-order pharmacies abroad, namely those in Canada, the U.K., New Zealand and Australia. Unfortunately for Maine, it is still part of the United States and therefore subject to the Food and Drug Administration’s rules, as a federal judge found last year in striking down the law. Re-importation is a problem that will have to be addressed in Congress, or not at all.

Another Democrat who opposed the 2012 importation measure is West Virginia’s Joe Manchin, whose daughter just happens to be the CEO of Mylan Pharmaceuticals. Familial support, however, will only reach so far; the best Manchin can manage for the much-maligned Mylan today is silence amid the heavy criticism many of his colleagues have leveled at the company’s price increases. Amy Klobuchar, D-Minn., went so far as to call for an investigation into EpiPens’ price increases since Mylan acquired the device in 2007.

Members of both parties are busy targeting Mylan as the pharmaceutical scapegoat of the moment for doing what everyone knew drug companies would do: charging Americans more than they charge anyone else in the world for the same products. These companies can get away with doing so only because Congress permits it. Health care lobbyists don’t get paid all that money for nothing, after all. Yet amid all the bleating and blathering from congressional members on both sides of the aisle, hardly anyone is seriously proposing another run at re-importation.

Notice I said “hardly anyone.” Hillary Clinton included “carefully controlled” re-importation in her campaign platform to reduce prescription drug costs (along with stopping “excessive profiteering” by drug companies by denying deductions for consumer advertising that every other legal business can claim and illogically demanding that they reinvest those dollars in developing new drugs that would receive shorter patent protection). Her rival candidate, Donald J. Trump, has also put drug re-importation among his top legislative priorities for replacing the Affordable Care Act – which Clinton has promised to preserve – with legislation that might actually do something to make health care more affordable.

If even these two candidates agree that drug re-importation is a good idea, maybe Congress will eventually fill this prescription to ease the political sting. On rare occasions, those can also be deadly.

Larry M. Elkin is the founder and president of Palisades Hudson, and is based out of Palisades Hudson’s Fort Lauderdale, Florida headquarters. He wrote several of the chapters in the firm’s book, Looking Ahead: Life, Family, Wealth and Business After 55. His contributions include Chapter 1, “Looking Ahead When Youth Is Behind Us” and Chapter 4, “The Family Business."

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