Matt dives into a specific healthcare topic to help those in the industry, and those outside of it, better understand the market drivers causing today’s healthcare challenges.

The FDA just signed off on Colorado importing its citizens' medicine from Canada. Sit with that for a second. A state government looked at the price its own people pay at the pharmacy counter, examined every domestic lever it controls, and decided that the fastest path to affordable medicine ran through another country.

Read it as a confession. The domestic pricing system failed so completely that Colorado went shopping abroad, filed the paperwork, and won federal sign-off to do it. The industry that built that pricing system keeps treating the moment like a footnote in a trade-press roundup.

I run an annual syndicated research program called ELAVAY. Every year my team asks patient advocacy organizations how they actually judge the pharma and biotech companies courting them. The answer comes back the same way every cycle. Advocacy organizations grade companies hardest on one thing: commitment to patient outcomes. Affordability is where that commitment either shows up or evaporates.

Colorado just turned that abstract grade into a headline. When a state buys its drugs from Canada to protect its budget and its people, every manufacturer with a patient assistance webpage and a mission statement about access should feel the floor shift. The advocacy community already feels it. They have been telling us for years.

So let me walk through what the data say, where the industry keeps lying to itself, and what the companies that are winning trust do differently.

Get the facts straight, because the details carry the weight.

On June 15, 2026, the FDA sent Kim Bimestefer, executive director of Colorado's Department of Health Care Policy and Financing, a letter authorizing the state's Section 804 Importation Program for two years. Colorado can now move toward importing certain prescription drugs from Canada through a single approved port in Detroit. The FDA requires testing and relabeling at every step. You can read the letter yourself in the FDA's media library.

Here is the part the press keeps fumbling. Colorado makes two. The FDA authorized Florida's program first, in January 2024. Two states now hold federal authorization to buy American patients' medicine from a foreign country, and a line of states stretches out behind them. Maine, New Mexico, Vermont, and others have laws on the books and proposals in motion.

One authorization reads as a fluke. Two reads as a pattern. A line of states behind them reads as a verdict on domestic pricing.

The number behind the urgency tells the rest. PwC published its 2027 medical cost trend report on June 11, 2026, and projected commercial group healthcare costs to climb 9 percent next year, the steepest single-year jump in 17 years. Specialty drugs and GLP-1 demand sit near the top of the list of drivers. Patients absorb that increase at the counter through higher deductibles and thinner coverage.

Colorado looked at that math and made a choice most states only threaten to make. It decided to source medicine the way a wholesaler sources inventory, by finding a cheaper supplier in another market. A state government should never have to broker drug deals across an international border to protect the people who elected it. Colorado did it anyway, and the FDA blessed it.

Importation never functions as a solution. It functions as a symptom, the visible spike on the chart that tells you the body has been fighting an infection for a long time.

The disease runs underneath. List prices climb faster than wages. Patient cost-sharing climbs faster than list prices. Copay coupons arrive with expiration dates and annual caps that run dry by spring. Patient assistance programs sit behind prior authorization mazes that exhaust the people who need them most. Every one of those mechanics works exactly as designed. They manage optics without touching the underlying cost a patient carries.

ELAVAY exists to measure the gap between what companies say about patients and what advocacy organizations experience from them. Year after year, the advocacy community rates commitment to patient outcomes as the single sharpest test of a partner. And year after year, affordability surfaces as the place where that commitment gets tested in public.

Importation programs expose the gap with brutal clarity. When a state government decides it can serve its patients better by buying from Canada than by working within the domestic system, it tells every manufacturer something direct. The people closest to patients, the advocates and the public officials who answer to them, stopped believing the system would deliver affordability on its own.

A fever demands two responses. Treat the symptom and find the infection. The industry spent years treating the symptom, fighting importation in court and in the press, and spent almost no energy naming the infection out loud. PhRMA and BIO opposed Section 804 importation on safety and supply-chain grounds and signaled they would explore every legal option. Cooley and Jones Day both documented the opposition when Florida won its authorization.

Fighting the thermometer never lowers the fever. The advocacy community watches which companies grab the thermometer and which ones treat the patient. They remember.

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Walk through the capital, and the story tells itself.

Pfizer spent close to $10 billion to acquire Metsera in late 2025, winning a bidding war with Novo Nordisk to gain a foothold in obesity drugs after its own in-house programs failed. Pfizer's filings and the major trade outlets, BioPharma Dive and Fierce among them, all put the final deal near that figure once you count the contingent payments. I have no quarrel with the strategy. Obesity carries an enormous disease burden and an enormous market opportunity, and a public company chasing both makes rational sense.

I have a quarrel with the priority math. The capital exists. Pharma deploys it at scale for the pipeline, for acquisitions, and for assets that move a stock. The same companies that find 10 billion dollars for a single obesity bet describe affordability programs as cost centers and trim them at the margin. They narrow eligibility. They cap assistance. They bury access behind utilization controls. Then they wonder why a state would rather shop in Canada.

Affordability competes for capital like everything else, and it keeps losing the internal argument. The money never ran out. Affordability simply sits in the policy and compliance budget, where leaders treat it as a risk to manage rather than a market to win.

Patients live inside that priority math. So do advocates. When a patient hits an assistance cap in April and a manufacturer announces a $10 billion deal in May, the advocate watching that patient draws the obvious conclusion. The money for affordability was always there. The will to spend it went missing.

The advocacy community keeps a longer memory than any quarterly cycle. ELAVAY captures that memory and turns it into a score. Companies that treat affordability as someone else's line item show up in our data as exactly what they are. Partners who talk about patients and budget against them.

The companies that improved their ELAVAY scores year over year share a pattern, and it has nothing to do with a sharper press release.

They moved money. They funded the advocacy function as a real capability instead of a line item that survives until the next reorganization. They built access infrastructure that patients can actually navigate, with assistance programs a human being can complete without a case manager and a calendar reminder. They funded advocacy partners without strings, resisting the urge to turn every grant into a marketing deliverable. The advocacy community noticed it all, and the scores moved.

Top performers treat affordability as a market access strategy, not as a compliance checkbox. They understand a simple sequence. Patients trust their advocacy organizations. Advocacy organizations watch how companies behave when the cameras turn off. Companies that show up early, before a pricing fight reaches a state legislature, build a reservoir of credibility they can draw on when the hard conversations arrive. Companies that show up only to defend a price arrive at the table with nothing.

Trust compounds like interest. Every honest action adds to the balance. So does its absence. A company that funds a patient organization's independent work for five years earns a hearing that no crisis-communications firm can manufacture in a week. A company that treats advocacy as a transaction earns the silence it paid for.

Colorado's authorization is the kind of moment that separates the two. The manufacturers who have built genuine relationships with Colorado advocates and officials have a seat at the table where this gets discussed. The manufacturers who treated those relationships as optional find out they hold no standing, no goodwill, and no warning. They read about the decision in the same trade roundup as everyone else.

Top-tier performers spend on affordability and advocacy before the room they cannot see makes a decision about them. Everyone else reacts.

Strip away the policy mechanics and the spreadsheets, and affordability comes down to trust.

A patient who cannot afford a drug stops trusting the company that makes it. An advocate who watches that patient struggle stops trusting the company too, and that advocate carries influence across a whole community. A state official who fields enough of those stories stops trusting the domestic system entirely and starts filing importation paperwork. Colorado just finished that paperwork. The trust ran out a long time before the FDA letter arrived.

Every manufacturer faces the same choice now. Keep treating affordability as the policy team's problem and keep losing the rooms you never get invited to. Or treat affordability as the clearest signal of commitment you can send, and start sending it before the next state goes shopping abroad.

Your access strategy already broadcasts your priorities to the people who watch most closely. The advocacy community reads that signal whether you intend to send it or not. The only open question is whether you know what they hear.

Find out. The 2026 ELAVAY report launches this season, and it measures the exact gap that importation programs expose: the distance between what your company says about patients and what the advocacy community says about your commitment to them. See where you score before your competitors do, because they are asking the same question about you.

When a state shops in Canada, the industry already lost the argument it refused to have. Get ahead of the next one.

Reach out to [email protected].