Defending “My Drug Problem”

Virginia Postrel’s March article on the availability of cancer drugs sparked enormous reader response, much more than the print magazine’s Letters to the Editor section could accommodate. Here she responds to some common criticisms from those letters.

Before embarking on this new discussion, I hope readers will read (or re-read) my original article, since the more emotionally and politically charged the subject, the more likely letter writers are to respond to something different from what appears on the page. Thus, in the minds of some readers, my cautionary tale about the tradeoffs involved in centrally controlling drug costs, told in part through the story of my own experience with the cancer drug Herceptin, became a brief for a particular health-care system—in this case, the status quo. And an article informed by a mountain of studies on Herceptin, drug-pricing, and treatment diffusion, as well as considerable reporting, was attacked for relying solely on personal anecdote.

On the first point, let me clear up a couple of misconceptions. Like any patient, I have many complaints about the current system. I, too, have wasted time convincing my insurer to pay bills for procedures obviously covered under my plan. I, too, have been bewildered trying to reconcile the strangely different ways in which medical center billing departments and the insurer classify exactly the same expenditures. And, of course, as a patient with a pre-existing condition who has in the past been happily self-employed, I am acutely conscious that my own options are now more limited than they once were.

Before my personal experience as a patient, I objected to the delivery of health insurance through employers, as many economists and policy analysts do. Employer-based health insurance unduly limits the flexibility of Americans to change jobs, work part time, or start businesses and amplifies the negative repercussions of an economic downturn like the one we’re now experiencing. I also know that the current system of reimbursement, led by Medicare, has taken a terrible toll on primary-care physicians in particular, driving many out of medicine and requiring others to skimp on care (spending little time with patients) or develop cosmetic side-specialties (Botox, anyone?) to subsidize their practices.

But acknowledging that the current system has problems and might be improved is a long way from believing that those problems can be solved simply—or that Americans can have, as many readers seem to believe, health care that is simultaneously cheaper, less likely to escalate in cost, more widely available, technologically innovative, and fully responsive to the desires of patients and physicians.

Wiping out administrative costs, often cited as an advantage of centralized health-care systems, might reduce the cost of care to a lower level, but those costs would continue to rise. The growth of medical expenditures in the U.S. is not caused by administrative costs but by increases in the technical intensity of care over time—a.k.a. medical progress. The technocratic magic of “scrutiniz[ing] new treatments for effectiveness,” as described in a January New Republic article, could limit cost increases only by denying patients some of the care they want and by blocking the adoption of newer and more expensive treatments. We know that Americans hate such limits. As a former aide to a Democratic congressman commented in response to my article:

Personally, I think people have very short memories on this debate. It was maybe 10–15 years ago that everyone was up in arms about the possibility of HMOs denying certain treatments or procedures, and managed care got a huge black eye. We had a national debate about whether you could sue your HMO for not allowing certain diagnostic screening procedures. Now, we’re really talking about the same type of denial of certain procedures, but the roles are reversed; huge chunks of the Democratic Party want the limits now, and the Republicans are saying no way, everything should be allowed.

In the early 1990s when patients objected to the limits of managed care, employers responded by shopping around for more generous plans and insurers became somewhat more lenient in defining coverage. Along with competitive pressures, lawsuits and state mandates also forced broader coverage. (Controversy currently surrounds coverage for autism treatments, which make the priciest cancer drugs look cheap by comparison.) The big difference between a centralized system and a competitive one is the speed with which adjustments can be made. In addition, private businesses are generally more easily sued and more subject to political regulation, especially at the state level, than a government health plan would be.

Let me give a few more readers their say and address some common themes. Bill Paine of Gainesville, Florida, writes:

Virginia Postrel’s opinion piece “My Drug Problem” presents only parts of the very important dilemma faced by all societies today, namely affordable health care for everyone. The operative words here are “affordable” and “for everyone.”

While taking New Zealand’s healthcare system to task for attempting to deal with the unbelievable costs associated with the cancer drug Trastuzumab (trade name Herceptin), she completely sidestepped the obvious question as to why this drug is SO EXPENSIVE in the first place. In an article in Scoop Independent News, discussing the very situation Postrel refers to in New Zealand, a representative of the drug manufacturer was asked why the drug was so expensive. His answer was “A lot of research and development that had to go into developing the drug.” When asked for a breakdown of the costs by the reporter, the spokesperson for Roche/Genentech replied, “No, we wouldn’t go into any more detail than that.” I’m not sure if it is prudent and wise to take something like this on face value, particularly given the scandals that have been uncovered involving corporate greed and malfeasance over the past several years. The pharmaceutical corporations provide no shining example of altruistic behavior, the last time I checked.

I live in Florida, a state that has anti-gouging laws on the books. Woe be unto a merchant trying to gouge consumers by charging $100 per sheet of plywood to desperate homeowners after a hurricane. Has there ever been any investigation into whether drug makers are gouging us all? Seems like the ultimate gouge to charge such unbelievable prices for drugs—particularly when the “customers” are those facing their probable demise.

Mr. Paine’s sentiments are echoed by David R. Work of Chapel Hill, North Carolina, the executive director emeritus of the North Carolina Board of Pharmacy.

Virginia Postrel omits the most important word from her article on cancer treatment: price. She and many other commentators on health care use the word cost when the true problem, particularly with new brand name drugs, is price. The actual cost of this therapy is probably in the range of pennies per dose but they charge hundreds or thousands of dollars. Pharmaceutical manufacturers charge and get any price they want for these items.

They also regularly increase prices. One would think that Pfizer, when they launched Lipitor would have set a price that would have returned their investment plus a profit. Pfizer has increased the price on Lipitor ten times in ten years! Physicians, hospitals, and pharmacies could never get away with that.

Drug companies claim that it costs them in the range of $900 million to bring a drug to market but that figure has never been subject to audit. I propose that, as a condition for FDA approval of any new drug, the manufacturer or marketer agrees to a price calculated by the General Accounting Office. This amount would consist of the actual cost to produce the product plus a per cent markup, all, of which is public record.

Both these letter writers assume away the extremely risky and expensive process of drug development. Genentech spent roughly $200 million to turn Herceptin into a marketable drug once the basic research had already been done at UCLA, largely with funding from Revlon. As large as it is, that figure understates the perils of the process. To the consternation of Dennis Slamon, the UCLA oncologist whose research and determination made the drug possible, Genentech nearly dropped the project several times along the way, because success was so uncertain. (The remarkable story of Herceptin is told well in Robert Bazell’s 1998 book Her-2, which is my source for the $200 million figure.) In retrospect, those close calls make Genentech look cold and short-sighted, but the drug could easily have failed, diverting scarce resources from other drugs and doing significant financial damage to a relatively small company. Expensive professionals working in the pharmaceutical industry often go for decades without working on a drug that makes it to market. The costs of a successful drug must also include all the costs of the many, many promising ideas that never work out. (The most expensive failures are the ones that look most promising and so go through the increasingly costly stages of animal testing, human safety testing and human efficacy testing before being rejected.)

Mr. Work’s specific prescription would corrupt the FDA’s approval process, which is—and should be—focused on scientific questions of safety and efficacy, not economic considerations. Long experience with price controls of all sorts suggests they dampen supply, for obvious reasons, while cost-plus payment structures encourage bloated costs. So we’d likely get fewer new drugs produced less efficiently. There may be a better system than the one we have, but Mr. Work’s certainly isn’t it.

Other letter writers were more forthright about rationing. Tim Daily of Portland, Oregon, writes:

Virginia Postrel almost makes a convincing argument in her article, “My Drug Problem.” What she and other proponents of America’s current health care system always ignore are the 50,000 uninsured. Yes, Ms. Postrel got her Herceptin, but because she got hers, thousands will die every day in the United States because they will never have any health care at all. No matter what kind of health care system we choose there are tradeoffs. Our current private system leaves many with nothing while some of us get whatever we need. My hope is that we can find a compromise system where every American will get some health care. If I have to sacrifice by paying out of my own pocket for expensive, new drugs then so be it.

Anne Richmond of Delray Beach, Florida, who identifies herself as “a stage-two breast cancer survivor who had excellent health insurance thanks to my employer,” calls for triage:

I was very happy to learn that Virginia Postrel’s health insurance company paid $60,000 for her Herceptin treatments. But who really paid for these treatments? The answer: her co-insureds or her employer. Unfortunately, the more drugs and treatments that are covered by an insurance company, the higher the premiums will be, leaving fewer people and companies that can afford the insurance. The net result: more people with no health insurance and more bankrupt companies like General Motors.

I don’t think any society can afford to give every one of its members every available medical treatment currently available. Society has to make choices. On the battlefield it is called “triage.” The USA has opted to provide medical care to the well-heeled and those employed by companies that provide health insurance. More limited health care is provided to the elderly, the disabled, veterans, and the very poor via federal and state governmental programs. (We already have socialized medicine. It’s just not available to everyone.) Anyway, my point is that Virginia Postrel’s narrow focus on one drug doesn’t add much to the debate on health care.

I’d also like to point out that even though Virginia Postrel would be $60,000 poorer if she lived in New Zealand, she would be out a lot more money if she got her care in the USA but had no health insurance.

Jedediah Daniel of Stanford, California, takes a stronger approach:

I’m glad Virginia Postrel has benefited from Herceptin treatment, and sadly she’s probably right that drugs like it might not be developed if every place had socialized, New Zealand–style healthcare. But she neglects to come fully to grips with a key reality of America’s existing health care “system.” When she says her Herceptin treatment cost her insurer $60,000, she’s not right: It cost all of us $60,000. Her insurer immediately passed those expenses on to every subscriber in its system in the form of increased premiums; indeed they focused those premium increases on subscribers fitting her demographic group. After all, America’s private insurance businesses are for-profit entities. The choice ought not to be between New Zealand’s or the UK’s awkward and disingenuous quasi-socialist systems and our own existing one, but instead ought to be a more sober assessment of whether health care is a right or a privilege. Before we attempt to create another sluggish government bureaucracy to administer our medicine to us, we’d be better off deciding a question no politician can be expected to realistically asses: Does it really make sense to treat the receipt of the newest and most expensive medicines as an inherent right, or should we instead recognize the inevitability of death and spend our treasure on making the lives of both the healthy and the ill better in other ways?

Mr. Daily claims that “Yes, Ms. Postrel got her Herceptin, but because she got hers, thousands will die every day in the United States because they will never have any health care at all.” There are, in fact, very few if any people in the United States who “never have any health care at all”—health care and health insurance are not the same, and those least able to afford health care are covered by Medicaid—and patients like me in fact cross-subsidize the uninsured, though to a lesser degree than we once did. By providing the world’s largest and highest-priced market for cancer drugs, we also subsidize the rest of the world’s patients.

Mr. Daily shares a common belief, expressed less dramatically in other letters, that there is somewhere a pot of money dedicated to “health care” which “society” divides between winners and losers. In the United States, at least, there is no health care pot, any more than there is a pot for housing or education or magazine subscriptions. There is simply an economy, which includes health care among other goods, and the amount we spend on health care grows out of the largely decentralized decisions made by individuals and organizations. As productivity increases and prices drop in some areas—food, clothes, entertainment—we can afford to spend more on health care (even without overall economic growth or increased health-care efficiency).

Like many people, Ms. Richmond seems not to understand the difference between a voluntary contract to share risks—insurance, in other words—and a forced subsidy. Employment-based insurance has many problems, but it is, in fact, a form of compensation. If The Atlantic did not offer health insurance, it would have to pay its employees higher salaries. It might opt for less generous coverage, as many companies do, but that, too, would be a way of reducing compensation. (Insurance costs covering current employees for current care are much less problematic than promises, like the automakers’, to cover retired employees in the distant future, when business conditions and medical costs may have changed dramatically.) There are plenty of tax distortions in our current system, but no one was forced to pay for my insurance.

As an alternative, Ms. Richmond wants to herd everyone into a bare-bones insurance system, presumably administered by the government, and then institute “triage”—eliminating insurance for costly treatments, the very kinds of payments for which the risk-pooling of insurance is most valuable. The short-term result would be that expensive drugs like Herceptin would be available only to affluent people with the resources to pay out of pocket. The long-term result would be that, with the elimination of much of the potential market, expensive drugs like Herceptin wouldn’t get developed in the first place. I also have to wonder what this bare-bones system would do about surgery and radiation therapy, which also cost a bundle, and whether Ms. Richmond wants to outlaw the supplemental insurance that is common in Canada and, of course, for Medicare recipients.

Mr. Daniel takes Ms. Richmond’s call for triage to its logical conclusion—let them die—but is murky about what he means by “right” versus “privilege.” We do not currently treat health care as a right. That we don’t is, in fact, what most letter writers are objecting to. Neither do we regard it exactly as a privilege, to be allocated to the worthy few or even to be limited to those who can afford to pay for it, directly or indirectly. Rather, it is a good, produced and purchased in a complex marketplace through a combination of individual, organizational, and political decisions.

Even this formulation is misleading, however. Health care isn’t a single good, nor, like food, is it easily defined in terms of a minimum to sustain life. Studying other countries’ supposedly universal systems only demonstrates how fraught the concept of “health care” is: one bundle of services in British Columbia and a less-generous one in Nova Scotia, one in England and another in Scotland, one in New Zealand before the election and another afterwards. Arguably the U.S. already has universal care, in the sense that everyone can get some care—if only from an emergency room—for some things, and that citizens (a critical word in this context) without money are covered by Medicaid. The real issue is how you define “health care.” What gets included is a matter not only of medicine and economics but of culture and politics.

A few letter writers address the specific questions of cost-benefit and comparative-effectiveness analysis. Michael W. Reeps of Staunton, Virginia, writes:

My mother-in-law had a nearly identical experience with breast cancer. Like Ms. Postrel, she fortunately remains cancer-free today largely due to Herceptin. But while it might make good copy for Atlantic readers, I certainly hope our national debate about health care reform doesn’t continue to be based on individual stories of triumph or defeat, for I can name equally as many women who underwent a similar ordeal, and are now quite dead.

More concerning is Ms. Postrel’s dismissal of New Zealand’s handling of Herceptin: “A purely rational calculation would suggest the opposite course: letting patients with advanced cancer die while shifting the money to early-stage patients who, if treated, might survive for decades.” It’s purely rational if you are the one with breast cancer, and are of the mindset that the free market is always rational, and can resolve any issue better than a semi-nationalized system like New Zealand. I would suggest both she and your readers take a further step back, with the same rational, and look at the bigger picture. New Zealand spends approximately a third of what the U.S. spends, per capita, on health care. Yet in almost every category of preventable diseases, infant mortality, and life expectancy, New Zealanders enjoy a better quality of life. Only in terms of cancer death prevention does the U.S. best them (by 5 percent). And this is a much poorer country, not known particularly for its healthy citizenry. But following Ms. Postrel’s logic, aren’t they in fact getting it right? They let the folks with cancer die (which they are far more likely to anyway) d and focus their efforts on preventing deadly diseases in the first place.

Am I advocating having let Ms. Postrel or my mother-in-law die, or go broke trying to get treatment, so that the vast majority of our citizens might be healthier? Only if you ask such an absurd question as part of a criticism of our present health care system in the first place. In which case, yes, we should.

Mr. Reeps completely misunderstands what I mean by “a purely rational calculation.” I mean purely rational by the stated cost-benefit standards of New Zealand authorities. The free market has nothing to do with it; in a free market everyone would get whatever care they had contracted for or could pay for out of pocket, without having to justify themselves to a government official. But using the “rational” cost-benefit analysis New Zealand claims to apply, if you were only going to cover one group, it would be more cost-effective to pay for Herceptin for early-stage patients while denying it to later-stage patients. Yet New Zealand did just the opposite. My point is that such decisions are not made rationally in a technocratic sense but respond to political pressures, including the pressure to maintain existing expenditures rather than zero them out to move the funds elsewhere. Perhaps Mr. Reeps imagines that U.S. politicians, unlike their New Zealand counterparts, would find it easy to tell cancer patients to accept their fate, but, if so, I have to wonder what country he is living in.

Carrie Channell, a graduate student in medical humanities and bioethics at Northwestern University’s Feinberg School of Medicine, is considerably more nuanced:

I fully sympathize with Ms. Postrel’s concerns about the trade-offs in a government modulated single-payer health care system. Her concerns about the availability of the most expensive drugs, technologies, and treatments are founded and serious. However, most of health care isn’t top-tier, and that is where the American patchwork system truly falls apart. In a very real and large sense, physicians are not making the decisions as to what is the best medical treatments; insurance companies and pharmaceutical companies do. Most people think doctors choose a drug based on if it’s the best one for them, whether allergy or heart medication. In fact, far too frequently it’s the drug sold by the sales rep who has built a relationship with that doctor, or with that hospital’s pharmacy. In part this is because doctors don’t have the time to review every study out there. And even though a government review process can be cumbersome and subject to politics, handing that education process to large drug companies whose primary (and often only) interest is profit is not an acceptable alternative.

Additionally, uninsured and underinsured people get their primary care through hospital emergency departments, which ultimately costs the taxpayers significantly more money than simply insuring these people would. It also contributes to why hospital costs are soaring. It is against the law to turn someone away from emergency (as it should be), but without some other form of insurance to fall back on, non-emergency patients will continue this practice … We need to see what systems have effectively dealt with specific problems and examine why they have worked, then apply that learning in a rationally compassionate way. I’m glad Herceptin saved Ms. Postrel’s life. But as an uninsured student living in America, I’d be dead now if it was me.

Without further information about her policy preferences, I can’t disagree with Ms. Channell’s call “to see what systems have effectively dealt with specific problems and examine why they have worked, then apply that learning in a rationally compassionate way.” I also agree that too many doctors don’t do their jobs, or at least don’t consider keeping up with current medical science to be part of their jobs. In many cases, those much-maligned pharmaceutical reps are probably better than nothing. I, too, would like to see more research on the comparative effectiveness of various drugs both done and disseminated. The government is one possible source of funding for such research; insurers, who have an obvious financial stake in improving medical efficiency, are another. But, given the variation in patients’ conditions, the rapid evolution of medical knowledge, and the different ways in which different people weigh costs and benefits, I do not want to see a national one-size-fits-all rule for what treatments may be used.

I am far from convinced that “simply insuring everyone” is the solution to overwhelmed emergency departments. There is some evidence that even insured people use emergency rooms, especially to get treatment for their children, because ERs are quicker and have more convenient hours than doctors’ offices. In this regard, the expansion of walk-in clinics, notably those operated privately by retailers like Wal-Mart and CVS, seems quite promising. While such clinics have been slow to build traffic, a new survey by WSL Strategic Retail finds that younger people and Latinos, populations less likely to be insured, are particularly likely to use them—and so are people who make more than $100,000 a year and value the convenience.

Also, while I am well known as a supporter of high levels of immigration, advocates of “simply” solving the problem by insuring everyone ignore the political explosion that would occur if a right to Medicare-level health insurance were extended to the 12 million or so immigrants in the country illegally. (About 44 percent of illegal immigrants lack health insurance, which means they make up about 5 million of the nation’s uninsured population.) Finally, I have to wonder why a presumably young student at a medical school has opted not to have health insurance—or even how, given the university’s policy that all students have health insurance, she has managed to do so. Ms. Channell seems typical of the many young and healthy uninsured people who have simply chosen to spend their money on other things. The 47 million figure is inflated by young, healthy people who could afford insurance but are simply playing the odds.

Lee N. Newcomer, M.D., of Minnetonka, Minnesota, raises the question of comparative effectiveness directly:

Virginia Postrel damned the Finnish study that used only nine weekly (not three as she reported) Herceptin treatments as “guessing” because only 232 women were studied. The statistical analysis demonstrated that this result could only happen by chance in one out of 100 studies. The striking benefit for the women treated with Herceptin—an 11 percent recurrence rate compared to 22 percent for those patients who didn’t receive the drug—allowed researchers to reach a valid conclusion with a small number of patients. The editors of the same prestigious New England Journal of Medicine that printed the one-year treatment studies involving thousands of patients also published this article. They knew the science was valid and they weren’t guessing.

American cancer specialists routinely accept any randomized trial with a statistical probability that the result was due to chance of less than 5 out of 100. The Finns have shown us that women can save themselves 43 weeks of difficult, expensive treatment. Additionally, four percent of the women in the one year studies developed toxic cardiac events while not one Finnish woman had this side effect. The next logical step, suggested by Dr. [John] Glaspy, would be a new trial comparing one year versus nine weeks of Herceptin.

It will never happen. American oncologists make about 60 percent of their income from the profits they accrue buying chemotherapy drugs wholesale and retailing them to payers and patients. The Finnish approach would reduce the physician profits from Herceptin by approximately 80 percent. Genentech, the drug manufacturer, has no incentive to sponsor a study that would reduce their sales by the same fraction. With those incentives it is not surprising that the trial hasn’t been proposed. The only surprise is why breast cancer patients aren’t demanding the trial. Perhaps Postrel’s article will confuse them into submission.

Postrel ends her histrionic article with the rationalization that our current system of payment if preferable because, “Different individuals and different organizations can make different trade-offs.” She is correct. A minimum wage worker in California needs 101 percent of his income to purchase a standard HMO plan for his family of four. He can elect to trade-off food, shelter, clothing, and his subscription to The Atlantic for health care coverage. Americans have decided to deny access to any type of care for 46 million citizens who are uninsured rather than pursue more cost effective ways to treat illnesses. New Zealand citizens believe that is a rather cruel trade-off.

I stand corrected on the nine versus three doses though, as Dr. Newcomer knows, the exact frequency with which Herceptin is administered depends on the patient’s chemo regime. In New Zealand, the nine smaller weekly doses were translated into three tri-weekly doses. (Similarly, I received Herceptin every three weeks, while some patients receive smaller doses weekly.)

More important, Dr. Newcomer misreads the very careful phrasing of what I wrote and what Dr. Glaspy said. If the Finnish study were all we had to evaluate the effectiveness of Herceptin versus no Herceptin, it would suffice to prove that the drug works. What we don’t know, because of the dramatic difference in sample size, is whether nine weeks of treatment work as well as 52 weeks. That would, indeed, be nice to know, and I wonder why insurers like Dr. Newcomer’s employer don’t fund such studies, given their financial interests. Perhaps funding is not the real problem. How exactly are you going to persuade patients to volunteer to take their chances with dramatically fewer doses of the drug? Dr. Glaspy does tell me, however, that there is a trial currently going on in France to compare six months versus a year of Herceptin.

I’ll give Michael Pignone, MD, MPH, an associate professor at the UNC Department of Medicine in Chapel Hill, the last word on cost-effectiveness:

The inefficiency of our “non-system” clearly affects our health: the U.S. spends 16 percent of its gross domestic product on health, but its health outcomes lag behind countries that spend fewer resources but deliver them in a more equitable fashion, such as France or Australia. Not surprisingly, the U.S. performs about as well as other wealthy countries on the delivery of “high-tech” care such as cancer treatment, but relatively poorer in such areas as delivering appropriate treatment for asthma, which requires better coordination of care across diverse populations.

Postrel chooses to use the example of Herceptin in early-stage breast cancer to support her argument against the use of economic analyses to guide coverage decisions. This particular example has limited relevance for the U.S. Multiple cost-effectiveness analyses have shown that, despite its high cost, Herceptin is both effective and cost-effective, with typical cost per quality adjusted life years gained under $40,000 per year, which constitutes a very good deal by U.S, spending standards. If economic analysis were used to guide decision making, they would provide strong support in favor of its coverage. Such support may not be necessary in areas like breast cancer that have strong advocates ensuring the availability of treatment; in other under-funded but effective areas, such as access to asthma treatment, smoking cessation counseling, or colon cancer screening, such analyses can be a strong driver to increase adoption by health systems, whether private or public.

I thank Dr. Pignone for buttressing my point that Herceptin is a very cost-effective drug, contrary to the earlier letter writers. I used it as an example not only because of my personal story but because its very cost-effectiveness makes it such a striking example. New Zealand chose to ration the drug (and not to cover it at all for early-stage cancer until July 2007) despite its significant benefits. As for the problem of coordinating care for chronic conditions, it is not really a question of payment systems but of management and patient compliance, and there is certainly room for improvement in both.

Finally, the story I told was not really about Herceptin per se but rather, about cancer drugs—and other expensive treatments—more generally. Not everyone missed that point. I received the following email from a woman who asked to remain anonymous:

To say your piece hit home for me is an understatement.

My story: I’m an American citizen who moved to New Zealand in 2005 to live and work as a primary teacher. In February 2007, I became a permanent resident, and thus eligible for health care in the public system. In July of 2007 I was diagnosed with stage II colon cancer. The small tumor was removed with a colon resection, but two months later, my cancer was restaged to IV as it quickly and aggressively spread to my left ovary with a tumor the size of a grapefruit. I became extremely sick (my stomach blew up with ascites to the point I look 6 months pregnant). I had the tumor and both ovaries removed. I was five weeks at Auckland City Hospital, and then two months later received a pretty aggressive regime of chemotherapy for six months. Yes, I received good standard treatment, but soon came to realize I was not in the best place for cancer: I was quite aware that I was not getting a very good drug called Avastin, a tumor-blocking therapy that is not only available in the U.S., but covered under most insurance plans. Thanks to New Zealand’s Pharmac, Avastin (like Herceptin) was not covered, and the only way I could have had it was to pay 1,000 U.S. dollars a week for it. Not an option. I was also aware that clinical trials in New Zealand, due to the small population and strict regulations, were sorely lacking.

So in July of 2008, when I realized the cancer was still in my system, I made the tough decision to leave my life in New Zealand (a partner, a job, friends) to get a better shot at life in the United States, solely based on what you said about the U.S. health system in your column. Yes the U.S. health care is fraught with problems. But I got incredible health insurance working as a part-time teaching assistant. So not only do I get Avastin, but the best health care possible, as I have access to the best cancer care centers in the country and probably the world. If I need it in the future, I have access to state-of-the-art cancer therapies like cyber knife, stereotactic radiation, drugs like Avastin, Erbitux, etc.

Thanks for shedding light on a problem that is not something particularly well known to Americans. Yes, our health care system has problems, but, if I were still living in New Zealand, I’d definitely be poorer, and quite possibly on the way to dead.