prescription drug prices in the united states prescription drug prices in the united states prescription drug list prices in the united states continually rank among the highest in the world. the high cost of prescription drugs became a major topic of discussion in the 21st century, leading up to the american health care reform debate of 2009, and received renewed attention in 2015. one major reason for high prescription drug prices in the united states relative to other countries is the inability of government-granted monopolies in the american health care sector to use their bargaining power to negotiate lower prices and that the american payer ends up subsidizing the world's r&d spending on drugs. according to a comprehensive 2021 review of the existing literature, the united states had higher prescription drug prices than all 32 comparison countries. the united states had 256% higher prescription drug prices than the comparison countries. history pharmaceutical drugs are the only major health care service in which the producer is able to set prices with little constraint, according to peter bach from the health outcomes research group, memorial sloan kettering cancer center, new york and steven pearson from the institute for clinical and economic review, boston. as of 2004, prices of brand name drugs were significantly higher in the united states (us) than in canada, india, the uk and other countries, nearly all of which have price controls, while prices for generic drugs tended to be higher in canada. in 2003, a republican-majority congress created medicare part d with the medicare prescription drug, improvement, and modernization act, which prevented medicare, the country's largest single-payer health care system, from negotiating drug prices. in effect, drug manufacturers in the us were allowed to set their own prices resulting in the unregulated pricing variation for prescription drugs. however, the government does employ drug pricing strategies for other smaller government health programs like the veterans health administration, the department of defense, the 340b drug pricing program (1992), and medicaid. in 2005, the government accountability office (gao) examined the change in us drug retail prices from january 2000 through december 2004 and found the average usual and customary (u&c) prices for a 30-day supply of 96 drugs frequently used by people enrolled in bluecross blueshield federal employee programs had increased 24.5%. the average u&c prices for brand prescription drugs increased three times as much as the average for generic drug. in 2007, the aarp published a series of studies showing that prescription drug prices have been rising significantly faster than general inflation. the american enterprise institute, a conservative think tank, criticized the methodology as overstating drug price inflation. attempts to repeal negotiation ban a february 2019 poll found 86% of americans in favor of allowing medicare to negotiate drug prices. a similar survey published in june 2021 found support at 81%, including 67% of republicans and 97% of democrats. twice, a democrat-controlled house of representatives passed a repeal of the negotiation ban, but the bill was killed in a republican-controlled senate: the medicare prescription drug price negotiation act of 2007, and the 2019 elijah cummings lower drug costs now act (h.r. 3). the elijah cummings lower drug costs now act was reintroduced in 2021, with democrats in control of the house, senate, and presidency. president biden supports a repeal of the negotiation ban, but did not include it in his american families plan, leading other democrats to push for it to be added. affordable care act in 2010, the patient protection and affordable care act, commonly known as obamacare or the affordable care act, was created. the goal was to increase the number of people who had healthcare in the united states and reduce the impact that individual healthcare spending had on households, especially since many americans had lost their health insurance coverage in the great recession. of its many provisions, two aim to reduce the burden of prescription drugs, both relating to the medicare part d coverage gap. under 2016 medicare coverage, people paid the deductible until they reached the limit of $3,310. they then entered the coverage gap where they paid about half the total cost for the drug. once the yearly out-of-pocket expenses reached $4,850, catastrophic coverage phase begins and the person only pays a very small amount for continued medication. in 2010, the first provision enacted immediately, was a one-year, $250 rebate to those people in the coverage gap to help pay for their medication. the second provision, enacted in january 2011, created a 50% discount on brand-name prescription drugs for seniors within the coverage gap. subsidies were to be provided until 2020, when the coverage gap was closed as of january 1, 2020. generic price spikes a december 2015 new york times editorial opined that "drug prices have been pushed to astronomical heights for no reason other than the desire of drug makers to maximize profits", pointing in particular to strategies by turing pharmaceuticals and valeant pharmaceuticals for rights to make and sell generic drugs which had administrative exclusivity and then raise the prices dramatically, which were widely condemned in- and outside the pharmaceutical industry. in response, the department of health and human services and both houses of congress held a public meeting and hearings respectively to investigate price gouging. in april 2017, maryland attempted to become the first state to grant the state attorney general the authority to sue drug companies for dramatically increasing drug prices. in april 2018, a divided panel of the united states court of appeals for the fourth circuit found that the maryland law violated the dormant commerce clause of the united states constitution. examples of affected medications include epinephrine auto-injectors and insulin. between 2011 and 2016, mylan was the only competitor on the market and raised the price of epipen by almost 400%, and consumers who were forced to pay the cash prices paid reported amounts of $600 or more for a two pack of epipen auto-injectors. due to public outcry and demand, mylan and teva pharmaceuticals later announced their releases of generics for epipen. however prices are still high for patients who need to pay cash price. the cash price of generic epinephrine still averages around $350 for a two pack of auto-injectors, and if a patient's insurance does not cover generic epinephrine they may need their primary physician to submit an appeal letter to their insurance on their behalf. trump executive orders president trump signs executive orders on lowering drug prices in july 2020 president donald trump signed four executive orders designed to reduce drug costs. one order permitted certain medications be imported in from canada and another order changed the way how discounts for prescription drugs can be negotiated for medicare patients. the most radical order mandated medicare to sell certain medications at the same price in foreign countries. however, this order may not go into effect as the trump administration plans on negotiating with pharmaceutical companies. despite the orders, health policy experts have claimed that they will have little or no impact on easing prescription drug costs for patients as they require implementation from the department of health and human services and that is very likely that lawsuits will be filed to stop the order. drug expenditures spending on pharmaceuticals can be defined as expenditure on prescriptions medicines and over-the-counter products, excluding pharmaceuticals consumed in hospitals, this has been mentioned together with drug price, but is not the same. in 1960, spending on pharmaceuticals accounted for 11.5% of u.s. national healthcare expenses, gradually falling to a low of 5.5% in 1980, before rising back up to 10.4% in 2000 and between 2000 and 2013, it ranged between 10% and 12%. in 2010, prescription drug expenses were 10% of the $2.6 trillion of total health care spending in the us, and its third largest portion after hospital spending and physician and clinical services. as of 2013, us "pharmaceutical spending", excluding hospital pharmaceutical spending, was $1,034 per capita in the oecd's international comparisons. in 2006, data from the medical expenditure panel survey was analyzed to determine the costs of healthcare for american households. it showed that 19.1% of americans were considered to have a financial burden due to healthcare spending as they spent more than 10% of their income on it. in 2003, data from the medical expenditure panel survey showed that only 9.5% of americans with medicare coverage had no prescription drug expenses, while 61.6% had prescription drug expenses up to $2,083, and 28.9% of those on medicare had expenses higher than $2,084. low income families tended to have higher prescription drug expenses during the year: 18.9% of poor households paid more than $4,724 compared to 13.2% and 12.5% who had prescription drug expenses between $2,084-$4,723 and $1–2,083, respectively. specialty pharmaceuticals in the us prescription drugs known as "specialty" drugs have become integral to the treatment of certain complex diseases including certain cancers and autoimmune diseases. additionally, some notoriously treatment-resistant infectious diseases such as hiv and hepatitis c have now become manageable (and the latter curable) using so-called "specialty pharmaceuticals". "specialty pharmaceuticals" are generally classified as such by possessing one or more of the following characteristics: high cost, high complexity, or high touch (i.e. requiring special monitoring, follow-up, or administration technique or assistance). the number of specialty pharmaceuticals has increased dramatically since 1990 when only ten were available; by 2015, 300 specialty products were available with more than 700 in development (pew 2016). the high costs of specialty pharmaceuticals, in addition to the generally high costs of prescription drugs in the united states, have generated a great deal of debate. it is becoming increasingly difficult, at both the individual and societal level, to afford to pay for such medications, as the use of specialty pharmaceuticals continues to increase along with their cost, which had, through 2015, risen faster than inflation for many consecutive years (aarp 2015). in 2015, 1-2% of the us population used specialty drugs, but these drugs represented 38% of drug expenditures for that year. a path forward must be found that provides specialty drugs to those who need them in an affordable, sustainable manner. a recent policy change by the centers for medicare and medicaid services will allow medicare advantage plans to utilize formulary management tools used in commercial plans, such as step therapy requirements, in order to manage drug costs, including specialty pharmaceuticals. chambers et al. may have identified one path to identifying the value of specialty pharmaceuticals using cost-effectiveness analysis:conducting cost-effectiveness analyses may be desirable to convey the value of a medication relative to a previous standard of care. even if a new therapy is expensive, its incremental cost-effectiveness may be within a willingness-to-pay threshold, as specialty drugs, though more expensive, often are also associated with the greatest gains in qalys. effects in 2006, data from the medical expenditure panel survey was analyzed to determine the costs of healthcare for american households. it showed that 19.1% of americans spent more than 10% of their income on healthcare related expenses. those americans were considered to have a financial burden due to their healthcare spending. one example is from a study done in 2018 from the american diabetes association that stated that the cost of insulin devices at a pharmacy can be almost $200 less than at the listed prices by analogs. a november 2020 study by the west health policy center stated that more than 1.1 million senior citizens in the u.s. medicare program are expected to die prematurely over the next decade because they will be unable to afford their prescription medications, requiring an additional $17.7 billion to be spent annually on avoidable medical costs due to health complications. the high cost of prescription drugs has required many americans to use cost-cutting measures and has also led to reformed healthcare legislation. prescription non-compliance and health effects another common way that people saved money, was to skip or reduce dosages or fail to fill a prescription entirely due to cost restrictions. one study reported that u.s. consumers pay prescription drug prices anywhere from 4 to 10 times more than other countries, even if they are more advanced or industrialized, and that prescription drug prices have increased twice as much as the inflation rate over the last 12 years. a quarter of americans taking prescription drugs said in june 2015, they