“Absolute nonsense” is not too strong a description for this statement. Firstly, drugs are expensive in the United States (much more expensive than in Australia), and secondly, the patient would have got the drug only if he could pay for it himself, if his insurance authorised it (assuming he had insurance), or if Medicare or Medicaid accepted it. Thus, if he had been living in the US, he may have had to pay a major part of the cost, and indeed, many patients in a similar position would not have had access to the drug in the US.

Most New Yorkers are very well educated about pharmaceuticals, much more so than the average educated Australian. Drugs are advertised on television and in other media. Coupons for free drugs are available in magazines. The patient takes the coupon to the doctor, gets a prescription and then mails in the coupon and script. Free drugs then appear. New Yorkers consider themselves to be discriminating, but they often end up with the latest and most expensive drug rather than the best.

Australia’s Pharmaceutical Benefits Scheme (PBS) may not be perfect, but many people think it is the best thing about Australian health care. It ensures that essential drugs are available at a reasonable price for all.

The US Medicare system supplies drugs for special categories of people (mostly the elderly), but doesn’t work in the same way as the PBS. US Medicare Part D, which pays for drugs, has the notorious “donut hole” — a gap between the initial coverage limit and the “catastrophic coverage” threshold. This is designed so the government can pretend that it provides pharmaceuticals to needy patients. The patient pays the first $290 of his or her drug costs, after which the plan starts to pay its share. This varies from plan to plan, but the insurance often pays 75% of the cost up to $2700. Once the patient and the plan have spent $2700, the patient has to pay all costs up to $4350. After that, the patient pays only a small proportion of the cost of drugs until the end of the year. Thus, between $2700 and $4350, the patient has to pay 100% of the costs out-of-pocket. I took this example from the official “Medicare and You 2009” booklet put out by the centres for Medicare and Medicaid services. Not only is there a significant gap in coverage above $2700, but the patient also pays a premium to be part of the process. So, in spite of the media hype, drugs are certainly not readily available for the average older person with limited means.

On top of this, drugs are restricted, as happens in Australia under the PBS. In fact, Australian doctors may be surprised to know that limits to prescribing in the US may be quite egregious. Thus, a physician may be able to prescribe one statin for one insurance company, but may need to prescribe a different statin for another insurance company. This often involves a phone call from the physician to a non-medical bureaucrat working for the insurance company. Authorisation is required for the drug cost to be reimbursed from insurance.

The US drug system is an example of the free market in action. Let us hope this type of free market drug system never arrives in Australia.

Speaking of arriving in Australia, this postcard was written shortly after my return to these shores. For those who are interested, working in health care in the United States is a very positive, stimulating, fulfilling experience. But in my opinion, the Australian health care system, for all its faults, is much, much better for doctors and patients.