Between the steps of the Vermont State House and the winding stairway that leads up to Dr. Nii Quao's clinic in Montreal are 139 long and bumpy miles of highway. It's a 3-1/2 hour ride that Shirley Wilford never thought she'd make - least of all to buy prescription drugs.
To Ms. Wilford, though, it's not just a bargain-hunting trip, it's a matter of the utmost importance. Diagnosed with diabetes, she takes three prescription medications, and her monthly bill - $236 in March - is getting harder to afford on the fixed income that she and her disabled husband live on.
Her answer: Go to Canada with seven other senior citizens and pay $82 for the same drugs.
Here in Vermont - and in other border states from Maine to Montana - busloads of people like Wilford are heading north to save money on the medications that their doctors prescribe.
The trips highlight the growing unease - even desperation - among many Americans over the high cost of drugs. Moreover, they bring into sharp relief the difference between America's free-market approach and Canada's subsidized system.
Yet even as many states and Congress move to rein in prescription-drug costs, critics worry that any move to emulate Canada - enduring a healthcare crisis of its own - could endanger America's system.
Whatever the solution, most observers agree something needs to be done at a time when Americans are spending $138 billion on prescription drugs each year.
"By any reasonable standard we spend enough to get what we need," says Alan Sager, a professor at Boston University who has testified before Congress about government-mandated price controls. "Other nations spend substantially less, and they make [drugs] available at a huge discount."
Realizing this, lawmakers nationwide are beginning to target the problem. On Friday, the Maine legislature passed a bill that calls on the pharmaceutical industry to lower their prices to Canadian levels or face government price controls. Vermont and several other states are considering similar laws.
Also last week, Republicans in the US House introduced legislation that would offer subsidized prescription-drug insurance to senior citizens.
Indeed, drug prices are a powerful issue for millions of voters nationwide. A report in Health Affairs, a policy journal, found that 42 percent of Americans without insurance report they do not fill prescriptions for financial reasons. Even among those who do have insurance, 17 percent refuse to fill prescriptions for the same reason.
Part of the debate centers around the role of Medicare, which does not offer a prescription-drug benefit. At a time when many physicians opt to use drugs instead of surgery, the lack of coverage has become a major issue.
To deal with this and other problems, some lawmakers see Canada as a model. North of the border, prescription drugs are sold at discounts ranging from 30 to 80 percent. The Canadian government buys medications in bulk, and its publicly funded healthcare system is both universal and government managed.
NOR are Canadians the only ones paying less for American-made drugs. In many nations worldwide, American drugs are sold at substantial discounts.
"Why do you need an American passport to get a 60 to 70 percent discount for a product made in the United States?" asks Peter Shumlin, a state Senator in Vermont. "America is the laughing stock of the industrial world on this issue."
Not so, say others. In fact, free-market advocates argue that the way America's health-care system operates is what makes it the global leader in pharmaceuticals and medical advancements.
"There are those who will tell you there is no price to pay when you force pharmaceutical manufactures to sell drugs cheaper," says Tim Ryan, executive director of Citizens For Better Medicare, a trade organization funded by the pharmaceutical industry and other groups. "There are real trade-offs. We have to be honest about consequences if we go down that road."
In Canada, for instance, the introduction of new drugs is often delayed and research and development is drastically reduced, he says. In addition, Canadians face long waits for many kinds of treatment, meaning that thousands are making the opposite trek, heading to America to receive healthcare they can't get in their own country.
"If you want to work in a regulated industry environment like a utility, expect the consequences of a utility environment," says Mr. Ryan.
For Vermonter Josephine Gentes, though, her primary concern on this day as she travels to Canada is her checkbook.
To get her Canadian prescription filled, she first visits a Canadian physician where she had a full consultation at a cost of about $35. Her Canadian doctor then prescribes drugs to fill her American prescription.
From the clinic, Gentes, husband in tow, navigates a tight stairway, clambers into a rented van, and heads to get her prescription filled at a pharmacy a few blocks away. Half an hour later, looking tired, she emerges from the store with three months medication - the legal amount that can be exported to the United States.
Her saving: $257.
Though a modest saving, it's a lot for Gentes. "It's worth coming up here for," she says.
(c) Copyright 2000. The Christian Science Publishing Society