In the comments on yesterday's post on planning for disasters people brought up the situation of medications. As with many things in how the US handles healthcare and drugs, this is a mess.

The official recommendation is to prepare emergency supply kits for your home and work that contain:

At least a week-long supply of prescription medicines, along with a list of all medications, dosage, and any allergies

Running out of some medications can kill you: running out of blood pressure medication (ex: clonidine, propranolol) risks strokes or heart attacks, running out of anxiety medication (specifically, benzodiazepines) risks seizures, running out of insulin risks a diabetic coma. For medications like these, a week's worth seems low to me, since the harm of not having them is very high and maintaining extra that you rotate through should be low cost.

Should be low cost, but is it? If I decide I want to stock an extra month's worth of non-perishable food and rotate through it this is just bringing an expense forward a month, and is relatively cheap. But that's not how it works with medication.

Let's say I go to my doctor and ask for an extra month's worth of my medication to keep on hand for emergencies, and they are willing to write a prescription. My insurance company isn't required to cover backup medication, so they don't, which means I'd need to pay the sticker price.

Now, the US health insurance system is a mess, and part of how it's a mess is that it's mostly not insurance. In the case of prescription drugs it is more of a buyers club. While an individual is in a poor position to negotiate with a drug company, an insurance company can often use its large membership to get lower rates. Many drugs are far more expensive when bought individually than when bought with insurance, so it's likely that my extra month's worth of medication would cost me much more than it would cost my insurance company. And that's in addition to my insurance not helping me pay for it!

This is also assuming that my doctor is willing to write the prescription. If I'm on benzodiazepines, which are a controlled substance, my doctor would probably get in trouble for writing that prescription. Legally, there's nothing I can do except get every refill on the first day it's available.

If you read patient discussions you see some strategies that are probably not legal:

  • Refilling slightly early each month and building up a surplus (doesn't work with controlled medications).

  • Getting the doctor prescribe a higher dose, but continuing taking the lower dose and saving the difference.

  • Skipping some days or dividing a dose to build up some slack.

  • Buying the medication from sketchy foreign websites.

The medical community is aware of this problem (ex) but policy here, especially for controlled substances, is pretty limiting.

It's hard for me to think of solutions here when the drug policy I'd advocate is substantially less restrictive than the status quo, but for people who have a decent chance of dying if their medicine is interrupted this is clearly not a reasonable approach.

What do other countries do?

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This is a good example of where the system makes it difficult to do sensible rational things.

It's also an example of how the medical system assumes it will always be there, will not make mistakes, don't you worry etc.

It is not just for natural disasters that you need a backup supply. I found out the hard way that the capriciousness of the medical system can really hurt you. I showed up at the doctor had he told me that the drug I needed was not longer available from him, and I had to see a new specialist and "requalify". There was no way this could be done before I ran out. No-one had thought to warn me that the rules had changed. In fact they had not changed, formally. There was just this silent 'crackdown'. The word was put out that you betta not prescribe that any more, or maybe you would get audited, or raided, maybe lose your licence or medicare accreditation - there are a lot of ways we can hurt you. Maybe there will be a complaint against you that will burn a couple of years of your life to fight it.

There was a similar recent case of this with the prescription opiate crackdown. This was not what affected me, but the situation was similar. People showed up at the doctor's for a renewal and were told "nope". Your choice is cold turkey or the street. Doctors were prescribing opiates like candy and then they were not. Too bad if you were caught up in it.

As for solutions, most people suggest that putting a little bit away over time is the only solution. It is a waste of time trying to persuade the system to help you put together a just-in-case supply.

In the case of insulin, dosage is too complicated and illegible for insurance to restrict people to the amount they're using without significant slack. This is good, because running out of insulin is much deadlier much faster than any other commonly-used medication.