How JAMA & Kaiser Family Foundation Studies Have Concluded Millions of U.S. Adults Import Medications

According to a study published in the Journal of the American Medical Association (JAMA), 1.5% of adults in the U.S. who take prescription drugs purchase them from outside the U.S. to save money each year. That’s about 2.3 million people. In 2016, my review of a similar set of data estimated about four million per year. The Kaiser Family Foundation’s 2016 poll data was used to support an estimate showing that 19 million people, 8% of the adult population, have imported lower cost prescription drugs for personal use. What’s going on? 

The JAMA study authors used 2015-2017 government data from the U.S. Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey (NHIS), which collected an assortment of health information from 61,238 individuals. As explained in the JAMA study:

“Survey respondents were asked whether they bought prescription drugs from a country other than the US to save money during the past 12 months. We defined respondents as purchasers of medications outside the US if they answered yes to the question.”

Past estimates, including my own, have also used NHIS data but may have extrapolated incorrectly. The percentages should be applied not to the general adult population but to those who take prescription drugs. The adult population is about 256 million. In this study, the sample population of 61,238 represented 152.2 million people who take prescription drugs. The JAMA study found that 1.5% purchased medications outside the U.S. to save money, which comes out to about 2.3 million. My past estimates looked at 1.6%, which was an earlier NHIS estimate of adults who import, of 256 million people, which came out to a little over 4 million people.

At the end of 2016, the Kaiser Family Foundation poll included a question about imports, asking 1,200 people the following: “Have you or another family member living in your household ever bought prescription drugs from Canada or other countries outside the United States in order to pay a lower price, or not?” Eight percent said yes. That 8% was extrapolated to 19 million. The JAMA authors are dismissive about Kaiser’s number, but they miss something fundamental. The JAMA authors state:

“The current estimate is lower than the estimate of drug importation reported by the Kaiser Family Foundation (approximately 19 million US adults), which was calculated with the simple extrapolation to the US population in 2016. Our population estimate of prescription medication purchases from other countries may be more accurate given a larger sample size (61 238 vs 1202) and the established representativeness of the NHIS data adults.”

Clearly, the fact that the JAMA study first extrapolates the percentage of the population that uses prescriptions drugs and the larger representative sample are tools for greater accuracy than Kaiser’s poll. But Kaiser’s number may be closer to the truth than the JAMA study implies. Kaiser never stated that its number, 8% of the adult population, reflected annual data. Its figure related simply to the number of Americans who have imported prescription drugs at some point! Let’s say 2 million Americans imported prescription drugs per year on average for the past decade. That gets you to 20 million. It explains JAMA’s new figure and the approximate accuracy of Kaiser’s data, too.

What I do not yet understand is the “Conclusions and Relevance” section of the JAMA report:

“The findings suggest that patients are not using prescription purchases outside the US to meet their medication needs. However, monitoring to promote safe administration of medications imported into the US should be continued.”

How is that the case? The findings show that 1.5% of American adults – about 2.3 million people – annually import prescription drugs to save money. Isn’t that “using prescription purchases outside the U.S. to meet their medication needs?” The data is strikingly clear that people who have reported skipping medication doses, delaying filling a prescription, or using alternative therapies, are far more likely to import medicine because of cost. It’s therefore crystal clear from this data that buying prescription drugs outside the U.S. can be exceedingly helpful for those struggling to afford it here.

The authors may mean that 1.5% is a small number, and generally Americans are not using importation. That would of course be true, but the way they phrase their conclusion is odd. I’ve asked the lead author in an email about that. If he gets back to me, I’ll let you know what I learn.  

Good Demographic Data on Personal Drug Importation

Kudos to its authors because the JAMA study has all sorts of interesting demographics about who is doing the importing: “Specifically, individuals who purchased medication outside the US were more likely to be…”

  • Middle age
  • Hispanic
  • Immigrant status
  • Higher educational level
  • Lower income
  • Lower levels of health insurance
  • Fair to poor health

Hispanic people were almost four times more likely to have purchased a prescription drug outside the U.S. (4.2%) compared to non-Hispanic white people (1.3%). Non-Hispanic Black people were least likely to do so (0.6%).

These statistics are easily explained by the fact that Hispanic people living in the U.S. are more likely be immigrants, have lower levels of health insurance and may receive prescription drugs from their home countries. It’s my deepest hope that those among them who are less proficient in English can benefit from the Spanish PharmacyChecker site.

Online pharmacies, importation, and safety in the data

The study found that people who are more likely to use the Internet to find health information, participate in online chat groups, and fill prescriptions online are twice as likely to import prescription drugs. That’s not surprising but it was good to see the data anyway.

There is no attempt in this JAMA study to analyze best practices and safety that might help the millions who are using online pharmacies to buy more affordable prescription drugs outside the U.S. to do so most safely.

The discussion on safety is limited to generalizations on the need to warn consumers about rogue online pharmacies, due to the threat of counterfeit and low-quality drugs sold in other countries and the associated risks from imports.

For the most extensive work on online pharmacy drug safety, see the work of Roger Bate here: Personal medicine importation: What are the risks, and how can they be mitigated?

Buying Drugs Outside the U.S. in the Covid-19 Era

Sarah Gantz, in her write-up about the study in the Philadelphia Inquirer, spoke to the authors:

“They say the pandemic, which has hit seniors and minorities hard and has financially strained thousands of families, could lead to more people turning to international pharmacies.”

I’m glad that came up as I wrote about it at the end of May here: Potential Importance of Personal Importation Will Rise as Tens of Millions Lose Health Insurance 

Drug Importation Regulations

The JAMA study barely touches the law on buying prescription drugs outside the United States. That’s because the authors’ interest is in demographic data not regulations. But their tone is kind of telling, even inspiring, of how it should be in America when it comes to buying medications internationally:

“Although the public is free to purchase medications outside the US, patients should be informed of potential risks they can encounter when using rogue internet pharmacies.”

I can tell you that we at PharmacyChecker could not possible agree more with the sentiment.  And on that note Happy 4th of July!

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