And Now A Word From Our Drug Sponsors . . .
(While We Keep Quiet)

Watch network TV news any morning of the week and you will see that, littered between reports on Donald Trump’s tweets and North Korea’s latest test missile launch, are drug ads for Farxiga (“Farxiga ready!”), Enbrel with golfer Phil Mickelson, Myrbetriq with a cartoon bladder pulling a teacher at inopportune times to urinate, or Linzess to treat constipation, among many others. Not just a few ads, but a virtual flood. It makes me reminisce for window replacement ads and used car commercials.
The FDA’s loosening of direct-to-consumer (DTC) drug advertising 20 years ago dramatically changed the landscape of TV ads and, to a somewhat lesser degree, print advertising. The FDA reports that the drug industry now spends $5.4 billion annually on drug ads. You can see the result on network TV, cable TV, and print media. Drug ads are aired during morning news, evening news, TV talk shows, prime time drama and comedy, in women’s magazines Good Housekeeping, Redbook, and O: The Oprah Magazine, the AARP magazine, even Popular Science. The average American TV viewer views nine DTC drug ads per day, totaling 16 hours per year. No doubt: Since DTC drug advertising has become a fixture on the American media scene, it has become a major advertising force.
Over the years, the FDA has agonized over details in DTC drug ads such as the depth to which potential side-effects must be listed, whether the indication for the drug can be stated, and how ads influence consumer behavior. But there is another aspect of such advertising that, I believe, has been overlooked, a phenomenon more difficult to gauge because it’s not about what is contained in such ads, but what is missing from media channels that host drug ads. Since DTC drugs ads have played an increasingly important role in media advertising, and thereby media advertising revenue, there appears to be a notable lack of in-depth or investigative reporting on problems in healthcare. There’s plenty of discussion about healthcare politics, but not issues in healthcare itself.
To be sure, the problems in healthcare are among the biggest problems the nation has ever faced, even threatening to cripple the U.S. economy. And, contrary to popular opinion, despite the extravagant sums being funneled into healthcare, we are not receiving the highest-quality care. According to the Commonwealth Fund, an independent foundation that studies healthcare quality worldwide, among the eleven most developed Western nations, the U.S. ranks eleventh in infant mortality, access, and efficiency/cost effectiveness, falling behind nations like England, France, Sweden, and the Netherlands, all of which enjoy lower healthcare costs.

Regardless of whether the healthcare system falls under some form of Republican reform or Obamacare, the cost of American healthcare remains at crippling levels, the highest of any nation on earth, consuming 17.5% of Gross Domestic Product (GDP). (The nation second in line with the highest proportion of GDP going towards healthcare? New Zealand, the only other nation on earth that permits DTC drug advertising.)
Watch investigative TV news shows such as 60 Minutes or 20/20, or the news, or other broadcasts that discuss societal issues and you will see virtually no reporting on the glaring problems in healthcare. There’s an occasional feel-good report such as The Health Wagon from CBS’s 60 Minutes that chronicled nurse practitioners working under difficult conditions in Appalachia. The relative paucity of negative healthcare reporting on 60 Minutes is, of course, in sharp contrast to the confrontational, take-on-the-bullies ambush interviews that long-time host Mike Wallace made famous, such as his 1967 report on a phony Chicago cancer clinic and laboratory providing kickbacks to doctors and committing Medicaid fraud.
Outside of non-commercial network, PBS, I’ve been able to locate shockingly few television reports that openly discuss problems in healthcare. Among the few are a 60 Minutes 2015 report on escalating prices for cancer drugs and a 2007 — a decade ago — ABC 20/20 report by John Stossel on problems with healthcare insurance. Print media, more than television, still retain a few publications that have hosted open criticisms of healthcare, such as the LA Times, Wall Street Journal, New York Times, Forbes, and The Atlantic. The New York Times ran an op-ed by Christy Ford Chapin recently titled “How Did Health Care Get to Be Such a Mess?” The June 2017 issue of The Atlantic published T.R. Reid’s “How We Spend $3,400,000,000,000.” Chapin and Reid’s pieces remind us of the enormity of the problems in healthcare despite the relative silence encountered elsewhere and how little vigorous debate there has been. But these pieces stand out in stark contrast to the absence of similar reporting by other print journalists and the near total absence from television reporting. The last investigative report from AARP I could locate, for instance, that was openly critical of healthcare, not just the politics of healthcare, was published over a decade ago in 2006.
Some might argue that the absence of in-depth healthcare reporting is because American healthcare is in fine shape and that any level of deeper scrutiny will simply yield heroic stories of nurses and doctors following their calling, high-tech hospitals delivering first class care. But the data — not the marketing — reveal something entirely different. You don’t have to look very hard to uncover countless examples of flagrant and excessive profit-seeking in healthcare. Witness, for instance, the $84,000 to $94,000 charged for a 120-capsule vial of the drugs Harvoni or Sovoldi to treat hepatitis C. Or the $5200 per month for a weekly injection of Enbrel that only partially reduces symptoms in some people, a drug intended to be administered for as long as a lifetime. Or even costs as pedestrian as the average annual healthcare insurance premium of $26,944 for a family of four, according to actuarial consulting firm Milliman. (To put this cost into perspective, the Federal poverty level in 2017 for a family of four is a total annual income of $24,600.)
Perhaps the fact that the media-viewing public is increasingly turning away from traditional television and print media and towards online competition such as Hulu, YouTube, Netflix and mobile media is further fueling neglect of healthcare reporting. Nielsen reports a nearly 50% drop in millennial TV viewership since 2011. As viewership shrinks and thereby the appeal to companies interested in running ads begins to retreat, TV executives are certain to become increasingly reluctant to air programming antagonistic to any source of ad revenues.
The problem will likely get worse before (it ever) gets better. The pharmaceutical lobby has been pushing legislatively for DTC advertising to permit promotion of “off-label” indications, i.e., uses not provided for by the original FDA approval. A new cancer drug, for example, could be promoted as a treatment for an inflammatory condition, or an antidepressant promoted as a treatment for “social anxiety disorder.” This has the potential to open the floodgates of drug advertising even wider.
The enormity of the healthcare problem, media reporting or no, can make some strange bedfellows. Of all industries to step forward to become champions of restraint, the health insurance industry is at the forefront. Many of the drugs advertised in DTC drug ads are specialty or biologic agents, the sort that command price tags of tens of thousands of dollars per year, not uncommonly over $100,000 per year. This is not the cost of an individual’s healthcare for a year, but the cost of a single drug. Insurer Blue Cross Blue Shield reports that, from 2013 to 2014, drugs costs increased 12.6%, eclipsing the rate of increasing overall healthcare costs. While a number of factors are driving increasing healthcare costs, such as fraud and waste (that alone total nearly half the U.S. military budget), increasing hospitals costs, and inflated costs for medical devices, drug costs are ballooning out of proportion to all other healthcare costs.
Ironically, the drug lobby has argued that DTC drug ads are permitted by freedom of speech, a form of speech labeled “commercial speech,” protected by the First Amendment. But, as drug ads come to dominate advertising dollars, I believe that we are witnessing the opposite: DTC drug ads are, in effect, blocking freedom of speech because of media reluctance to air any message antagonistic to the pharmaceutical or healthcare industries. If a reader would like to understand why his health care insurance premium just increased 16% over last year even though no personal change in health status occurred, he/she is unlikely to obtain answers from the media. If a health care consumer fails to understand that the $5,000 per month injectable agent just prescribed for inflammation could be replaced by an agent costing 80% less, he/she will not have gained that awareness by hearing an investigative report on TV or reading about it in a lifestyle magazine.
I believe that Big Pharma has therefore essentially bought and paid for a gag order on the media. Imagine a series of reports on an investigative television news report detailing fraud, excess, unrestrained drug prices, personal bankruptcies from healthcare, conflicts of interests among doctors and hospitals, rampant bias that plagues clinical studies — why would a drug manufacturer allow their ads to be broadcast during the show? Obviously, they would pull their ads as fast as you can say “Movantik,” “Otezla,” or “Taltz.”
A solution? Clearly, banning DTC drug advertising would reverse the entire phenomenon, but efforts to repeal legislation allowing DTC advertising have fallen flat at every turn, given the effectiveness of the pharmaceutical lobby. As individuals, we are simply too small a force to counter such tidal waves of profit-driven behavior that move billions of dollars. I therefore personally support media outlets that have the courage to publish pieces that openly debate healthcare issues. I no longer watch network TV news but only PBS or BBC for my news. I choose to read print media that do not contain drug ads. I avoid websites that host drug ads. If we cannot effect change from the top down, perhaps we can exert an impact from the bottom up. But we must be able to talk about it in the open.
