The price of prescription drugs is too high. This is a global problem on which we can agree with Donald Trump. This week the UK’s National Institute for Health and Care Excellence (NICE) refused to recommend two new drugs for Alzheimer’s disease for use in the NHS (doi:10.1136/bmj.r1270).1 The decision may seem unfair to people seeking fresh treatment options, but NICE’s job is to ration the rollout of new technologies, which is especially important given that we’re digging at the bottom of the national money pit.
NICE, an internationally respected organisation for evaluating new technologies, considers both clinical effectiveness and value for money. It has decided that donanemab and lecanemab “do not demonstrate sufficient benefit for their high cost.” Inevitably, such judgments anger drug companies seeking to profit from it, patient groups advocating for availability of breakthrough medicines, and patients and families seeking hope in a new treatment. Politicians can be disappointed too, since they value the economic benefits that accompany a flourishing pharmaceutical sector.
Hence the surprise in Trump’s overtly aggressive approach to the drug industry. At least three issues are worth considering here. First, Trump and his staff are expert at identifying a fault line. Does WHO need reform? Who would disagree? Could Denmark have done better in its stewardship of Greenland and its indigenous people? Probably, yes, and even Danish people share this view. Is the drug industry charging too much and making obscene profits? You’ll find no disagreement at The BMJ. Where the analysis falls apart, however, is in the solution or the agenda behind it—which tends to make matters worse rather than better.
Second, the US’s health system is the most expensive in the world despite its population health remaining far short of being the best. It’s a system riddled with stark inequalities. Yet the cuts in Trump’s One Big Beautiful Bill Act are projected to make 7.6 million more people uninsured, while causing another 1.3 million people to go without the medicines they need (doi:10.1136/bmj.r1250).2 The same study predicts more than 16 000 additional deaths a year. High drug prices in the US are partly corporate greed and partly the product of a complex, bloated system.
Third, drug companies are overcharging us for medicines—everywhere. Companies will deny it, talking about high research and development investments to justify their pricing policies, but this is an argument built on sand. As an analysis in The BMJ found, “From 1999 to 2018, the world’s 15 largest biopharmaceutical companies spent more on selling, general, and administrative activities than on research and development” (doi:10.1136/bmj-2022-071710).3 The $7.7tn (£5.74tn) in revenue those companies generated during that period was about double the costs of investing in research and development, sales, and administration.
Global scandal
The hypothesis that drug companies are enjoying sky high profits at the expense of public finances is entirely plausible. The US is particularly hit by this, as Trump rightly identifies. A report by the Rand Corporation concluded that “Americans pay drug prices 2.78 times the average across 33 countries in the Organisation for Economic Co-operation and Development” (doi:10.1136/bmj.r1142).4 However, Trump’s claim that high drug prices in the US are subsidising lower costs in Europe and elsewhere, or that the US’s drug companies are being “extorted” by other governments, is a fantasy.
The answer isn’t to raise prices outside the US. Even if companies do publicly raise prices, behind closed doors they will reach national agreements that undercut those published prices. Yes, the US has a particular problem with drug pricing, but prescription drug pricing is a global scandal. The pharmaceutical enterprise is geared towards further growth in outsized profits. This is a shameless effort, obfuscated by good intentions.
If the drug industry were really motivated by improving the public’s health, it would slash drug prices and therefore profits everywhere. It would give drugs to poor countries free of charge or at massive discounts. It would acknowledge how it oversells benefits and hides harms. It would stop the manipulation of science, academics, patient groups, charities, and health systems. For all the good the drug industry does, it comes at a heavy cost that extends far beyond overpricing. If the totality of pharma’s crimes and misdemeanours is what Trump wants to tackle, then game on.
