Resolving the Massachusetts Paradox

Resolving the Massachusetts Paradox The biopharmaceutical industry’s crisis communication plan begins at home By Peter Kolchinsky POLICY | CULTURE | BIOTECH aerial view of high rise building at daytime Photo by Osman Rana on Unsplash Photo by Osman Rana on Unsplash This comprehensive article is meant for a highly specific set of decision-makers and is written for the age of AI. You can give AI this article and engage in a discussion with the AI; I trust the AI will glean enough context from all I’ve written to do a decent job of customizing answers to your specific questions. Give it a try. And for those who prefer to listen rather than read, here's an audio version of this article read by the author, with a couple of bonus asides. September 15, 2025 In Washington, senators and representatives usually fight for their states’ economic interests. Why then, when it comes to the biopharmaceutical industry that is so important to Massachusetts, are we such an outlier? Our Senators led the charge that resulted in the pill penalty. They urge for price controls to be expanded to all medicines and be applied earlier. And they did it because that’s what Massachusetts voters wanted them to do. We can’t expect our elected representatives to act differently until voters change their minds about our industry. In this article, I’ll examine the origins of this Massachusetts Paradox, what kinds of biopharma-related policies Massachusetts voters (and thus who we send to Washington) should logically support, and propose a new approach to rallying our neighbors to support those policies. Our campaign should be rooted in a kind of engaging storytelling that all of us in the biopharma ecosystem, from startup to pharma and from investor to banker, can and should contribute to. I’m talking about marketing, communication, education, and brand building, not lobbying. As an industry, even in Massachusetts where we have the home field advantage, we’re terrible at connecting with the public. The majority of our creativity and communications effort goes into marketing our wins (e.g., DTC ads). Would the NFL have any fans if it played its games in private and then promoted the winner of every game? Hardly. Fans are forged by bringing them along on the quest to victory, with all its pitfalls, and letting them bond emotionally with the players. People protesting Pharma split screen w/New England Patriots fans We must bring the audience into the R&D ecosystem itself and let them see who we are if we’re going to succeed. Only when the audience has connected with us as people, witnessing first-hand our effort, passion, struggles, and failures, will it tolerate and maybe even celebrate our high-priced wins they’re already familiar with through traditional DTC-marketing. Only then will they care to learn to hold insurance companies accountable for making covered medicines affordable when patients – which is to say all of us eventually – need them. Politicians will do what voters want them to, so we have to inspire them to want the biopharma industry to thrive and show them what kind of policy makes that possible. And I mean show, through character-driven storytelling, not tell via fact-heavy op-eds. Rather than delegate this effort to a few industry lobbying groups, I propose a MA-rketing Coalition inclusive of any companies, non-profits, universities, and state agencies that are inspired to contribute ideas, money, people, and follow-through, collaborating and competing to engage the public. I’ll explore key points and terminology that all members should align on, examples of what we could produce together, the early efforts of No Patient Left Behind and others that have kickstarted this campaign, and which metrics would indicate that we’re on the right track. If you're already compelled to join, then sign up here and get engaged. Plus you can learn about related initiatives on their website here. Massachusetts is merely a laboratory for this communications R&D effort. Once we have developed the messages and materials that align Massachusetts voters with their own interests, our campaign can extend to other states. Ultimately, our goal is to inspire America to solve affordability through insurance reform to lower out-of-pocket costs and to stop threatening price controls on novel medicines, preserving our innovation ecosystem. Table of Contents Part 1: Recognizing the Paradox Targeting the hometown heroes Imagine if Michigan hated car companies and Iowa hated farmers Part 2: Redirecting voters to constructive reforms Part 3: The MA-rketing Campaign Owning our motivation The work of the MA-rketing Coalition Let’s capture our most exciting stories Multi-media, Omni-channel Heroes and Villains Part 4: First, we must align on core concepts Let’s not compromise truth for engagement Part 5: How we’ll know MA-rketing is working Part 6: What MA-rketing cost? Content Distribution What can we afford? Part 7: Commitment, for the long run Part 1: Recognizing the Paradox You can’t go to a youth soccer game in suburban Boston without meeting parents who work in biotech. Just the smaller biotech companies headquartered in our state are responsible for 15% of the country’s drug development pipeline, not even counting the contributions of all the pharmas that have R&D facilities here. If all the biomedical innovation in the universe has a center, it’s in Massachusetts. We're the best in the world at it. And biotech matters to Massachusetts. Our 117,000 direct biopharma jobs fuel many more in sectors like construction, legal, accounting, supply-chain, and retail – roughly 350,000 Bay Staters owe their livelihood to the innovative medicines business. That economic flywheel spins off more than $110 billion in total annual output. I'm proud to base my firm in Massachusetts, and I'm proud that we create many companies and many jobs here. But in what I've come to refer to as the Massachusetts Paradox, those same companies are constantly vilified by our own legislators. In the horror movie that is public opinion of the biopharma industry, the call for price controls on novel medicines – which make investors run away as effectively as any vengeful slasher in a hockey mask – is coming from inside the house! people walking on street between high rise buildings during daytime Photo by Vika Chartier on Unsplash Photo by Vika Chartier on Unsplash If Massachusetts can’t rally as a team in support of its economic crown jewel, then what hope is there of the rest of America embracing the value of our industry? And the Massachusetts Paradox only happens to focus on biotech at the moment; what will happen to other segments of our economy that have big price tags, such as climate tech and education, if/when Massachusetts helps enact counter-productive policies due to a failure to understand their value to our state and to the world? We have to pay for what we value and, especially when it’s a core export of our economy, it makes sense to let everyone else know that it’s worth paying for, too. If that seems logical to you, then it’s hard to unsee how illogically and self-destructively Massachusetts is behaving. Targeting the hometown heroes Our home-grown biopharma jobs aren’t just good jobs; they’re also jobs that do good. Medicines restore life, keep families together, allow people to remain employed, and help people avoid costly hospital stays. Inventing medicines boosts our local economy, improves the lives of Massachusetts residents, and ultimately saves us money since medicines can go generic and become inexpensive whereas hospitals never go generic. With proper insurance that doesn’t charge high out-of-pocket costs, medicines can be both profitable for our companies and affordable to patients. Massachusetts leads on this front with the country’s lowest uninsured rate (3%), thanks to the Obamacare precursor Romneycare. black and white UNKs coffee store Photo by Maxence Bouniort on Unsplash Photo by Maxence Bouniort on Unsplash Medicare’s own data show hospitals consume 31 percent of US health-care dollars; novel medicines just 8 percent. And because the intellectual property, headquarters, and high-margin manufacturing for those drugs are disproportionately likely to be situated in Cambridge, Boston, Worcester, Framingham, Lexington, Watertown, and Lowell, Massachusetts captures a disproportionate share of that revenue. If the world spent more on more and better medicines, a large share of those profits would flow to Massachusetts and expand our local economy. By comparison, hospital spending is local; if the world spent more on hospitals, it would do nothing for Massachusetts. Arguably everyone in the world should want to encourage the invention of more and better medicines, but Massachusetts residents especially should be the biopharma industry’s biggest fans because of how its success powers our state economy. We enjoy medicines’ immense benefits because investors – particularly providers of early-stage venture capital – believe a risky decade-long slog from discovery to approval can earn a return. But the price-control politics unfortunately espoused by our own senators undermines that confidence. Senator Elizabeth Warren’s January letter urging the President to “cut drug prices” through government-imposed price caps is only the latest salvo in a years-long campaign to shrink the margins that fund future cures. Senator Ed Markey has marched in lock-step. We’re lucky there are some outliers. Representative Jake Auchincloss, a fellow Democrat, has warned colleagues that undermining intellectual property laws is bad for Massachusetts' economy and for U.S.-led innovation and spoken against price controls on novel medicines. We should be examining these differences in views amongst our elected representatives and figuring out what messages in what forms would get voters to realize that Congressman Auchincloss is actually advocating for their economic interest and ask the same of other politicians. Even leaving aside all the reasons why it’s objectively good to invent medicines for diseases people still suffer from, voters should at least be economically self-interested. If voters really care about jobs – as polling suggests they do – they should demand that our Senators and other representatives support the Epic Bill, which would fix the pill penalty baked into the Inflation Reduction Act by giving small molecule drugs that same 13 years on the market that biologics get before Medicare price controls can kick in. But because voters don’t understand this issue (it's pretty esoteric) they continue to support representatives who are trying to make the pill penalty even harsher. [Update: Case in point: In November 2025, Mass. Congressman Richard Neal introduced a bill that would expand the IRA's "Pill Penalty" to insurance plans in the commercial market -- NPLB's analysis of the catastrophic impact that would have on innovation is here.] Just as it’s painful watching people fall for anti-vaccine misinformation, leaving their kids exposed to measles, it’s painful to watch as Massachusetts fails to grasp the workings and virtues of the biomedical innovation at which it excels. Imagine if Michigan hated car companies and Iowa hated farmers Massachusetts really stands out as a state that isn’t even curious about why its voters are so intent on harming their economy. I think it hints at a bigger vulnerability of America as a whole: we take good things for granted, aren’t curious about how things work, and demand the wrong fixes to real problems. This risks making things worse instead of better. But I’m not blaming voters. Instead, I hold our own industry accountable. All of us. It’s absurd how little effort our industry and our state government has made to engage the public in ways that might lead people to appreciate that biopharma companies are innovators Americans should be proud of. I say “little” because there are actually nascent efforts, such as No Patient Left Behind’s Community Quest videos and emerging campaigns from some large pharmaceutical companies like Lilly and Pfizer. We are one of America’s most hated industries because we’ve largely taken for granted that the public would love us for our treatments and cures, even if many people were confused about where the money for it all comes from and who is accountable for making medicines affordable. We were so thoroughly impressed by our own scientific breakthroughs that we didn’t think we needed to effectively correct any misinformation. Instead, we paid lip service to the problem by publishing academic pieces that almost no one read and writing op-eds about innovation that clearly didn’t persuade enough people to think of us as hometown heroes. I’ve done my share of that. The results speak for themselves; courting Massachusetts voters by promising to punish the evil drug industry remains a winning political strategy. Michigan’s delegation doesn’t write op-eds kneecapping Ford or GM. Iowa’s representatives don’t campaign against farm subsidies. Texas senators unwaveringly defend oil and gas. Yet here in the Bay State – where 18 of the world’s 20 top pharma companies maintain R&D sites to invent new ways to combat disease – we see bizarre virtue in gutting our own world-leading industry. This paradox tends to be ignored though arguably should be of interest to every local newspaper. No one sees it because no one really thinks of the drug industry as vulnerable. Come now, will price controls really take down something so big and powerful? Yes, actually. Investors decide the fate of anything that requires their money and the drug industry is fueled by investment. The rules of finance and economics make it quite clear what happens if you pass something like the pill penalty; investors clear whatever zone the penalty applies to. If only voters understood the facts. Nothing a few classes on economics and finance won’t fix. green corn field under blue sky during daytime Photo by Benjamin Jopen on Unsplash Photo by Benjamin Jopen on Unsplash Sadly, people won’t learn economics and finance for the sake of the drug industry, and yet we still have to discover a way to teach these concepts to Massachusetts voters or somehow inspire them to vote as if they understood. Vote yes on insurance reform to lower out-of-pocket costs. Vote no on price controlling novel drugs. Whether through understanding or trust, it’s the outcome that matters. Considering all the problems we tackle and solve with our collective brainpower and ingenuity, this can’t be the hardest problem we face. We have to turn our sights on inspiring Massachusetts voters to see the difference between facile and truly constructive solutions. Our Senators should not be calling for Massachusetts insurance plans to pay as little as Canada does for innovative medicines. They should be calling for the Department of Commerce to get Canada to pay its fair share for them instead of freeriding on Massachusetts, as other Senators argue on behalf of their states’ exports. But you can’t get a Senator to go against their voter base. That’s why this article is not written to Senators Warren and Markey. They will do what they believe voters want them to do. So we have to inspire voters to change what they ask for. That requires engagement and information. Because voters need to understand that without market-based pricing and an expectation of profits, investors will invest elsewhere; scientists and their salaries will follow. Even if we later reversed course, the next wave of biopharma jobs might pop up in North Carolina, or Singapore, or Dublin. Is that good for Massachusetts? Definitely not. That’s one message we can deliver. There are many others. It’s not easy to teach what “market-based pricing” is without losing your audience in the first few seconds, and yet we must. What form will our messages take? Ads in local papers? Op-eds? Videos? Exhibits at the Museum of Science? Billboards? Movies? Tiktok videos? We need to figure out the right vehicles for the right messages and pay for their distribution. Who will be the messenger? A disembodied voice? An AI-generated avatar? A doctor? A scientist? A patient? An executive? All of the above? Every business has a marketing department that experiments with ways of attracting new customers and juicing repeat business. They operate in competitive marketplaces where everyone markets their hearts out as creatively as they can. Between Democrats pushing for price controls on novel medicines and Republicans pushing for rolling back insurance, Most Favored Nation international reference pricing, and cuts to NIH funding (a lot of which flows to basic science research in Massachusetts), one might think that the policy threats to the Massachusetts economy would inspire Massachusetts to invest in creative and productive marketing to keep its “customers” on-side. The Massachusetts State House Photo by Samuel Yongbo Kwon on Unsplash Photo by Samuel Yongbo Kwon on Unsplash We should build a coalition to do just that, one that will stop at nothing to focus group the hell out of messaging that connects with voters in Massachusetts and all over America to keep them interested in funding basic science, preserve comprehensive insurance that pays for medicines with low out-of-pocket costs, and make sure that price controls don’t touch novel medicines for the period of time the patent system intended for them to be branded (13-14 years). We need to inspire Massachusetts voters and voters everywhere with stories of heroic innovators battling horrible diseases – with stories of patients that make every disease feel personal and remind us that we are all patients – and let everyone know that Massachusetts is the epicenter of all our hope for cures. Massachusetts is a business. It lives and dies by its economy. And yet it has essentially no marketing department at a time it badly needs one. Let’s fix that right away. If it works, the paradox will be resolved and Massachusetts representatives will go to Washington to work on pro-innovation reforms. That’s not the same as giving big pharma everything it might want (please let us charge high prices for our drugs forever! Hmmm, no.). But it’s definitely not price controls on novel medicines. Part 2: Redirecting voters to constructive reforms Drug pricing does need reform – middlemen called pharmacy benefit managers (PBMs) extract billions without adding clinical value. There’s a great place to start turning over rocks. Massachusetts should be all-in on insurance reforms that lower out-of-pocket costs, not on price controls that punish the very innovation that leads to new cures and turn away investment that funds so many jobs in our state. Capping out-of-pocket costs would acknowledge that we all already paid for proper treatment when we paid our premiums and no one should have to pay a second time out-of-pocket when they actually need medicine, especially if it’s more than they can afford. We should lead a bipartisan coalition to strengthen market incentives, not weaken them. I applaud Rep. Auchincloss for doing exactly that in calling for a fix to the pill penalty as part of a push to cure Alzheimer's, as well as for leading on “muscular” PBM reform to reduce drug prices at the pharmacy counter. There are problems with drug pricing and affordability that need fixing. Namely 1) some medicines enjoy market exclusivity beyond what is intended by the patent system, which means society is overpaying for some old drugs (i.e., the industry is enjoying “rents”) and 2) some people don’t have proper insurance and can’t afford the medicines they need. So the proper reforms would be: Capping out-of-pocket costs that insurance plans are permitted to charge if they want to claim they are selling proper health insurance and Imposing price controls on old drugs if they fail to go generic as intended by the patent system. That’s it. Those two reforms would be good for patients, good for innovation, good for all of society, and especially good for the Massachusetts economy. Rep. Auchincloss has spoken many times about the curse of cost disease (a.k.a. the Baumol effect), which describes how quality-of-life gains will be held back by our continued dependence on labor-intensive services. The solution to this cost disease, he explains astutely, is to swap out our dependence on hospitals and doctors for medicines that keep us healthy and productive. As manufactured goods, medicines actually can fall in price in a way that services can’t. Basically, drugs go generic, but hospitals don’t, and therefore we should be doing all we can to invent more and better medicines before we end up spending ever more of our paychecks on healthcare services. If all of America recognized this, Washington would be very pro-Massachusetts. Before we can hope for that, we should consider what it would take to get Massachusetts voters to elect more people alongside Rep. Auchincloss who would be similarly pro-Massachusetts. Part 3: The MA-rketing Coalition Owning our motivation Facts and logical arguments matter to the integrity of a protracted campaign, but it’s the personal stories that change hearts and minds. We need to step forward and connect personally with the public. For too long, our industry has hidden behind others, asking academics, patients, and doctors to speak for us. Why? The vast majority of the people whom I’ve gotten to know personally in our industry are people with powerful personal motivations to do good in the world. The world should see that. The way we talk about patients like they are a separate stakeholder from scientists, investors, and executives suggests that we have bought into the idea that we’re not trustworthy messengers of the importance of novel medicines. How’s that? We’re all human. We get sick. We’re all patients, now or eventually. Many of us love someone who needs a medicine that hasn’t been invented yet. Why do we accept that just because we make medicines or invest in them, we aren’t also patients and advocates? For many of us, our work is personal. Most people can’t imagine what it feels like to help bring a medicine into this world that helps their child. Or to create a medicine that treats a disease that took the life of someone dear to them. Anyone who actually met a drug developer who has done this would never think of them as just being in it for the money. Yes, our medicines have to be profitable. Profitability is a necessary constraint on all of us who wish to bring a new medicine to market; there’s no way to get the funding to develop a medicine without making sure that investors believe it might be very profitable. But having to generate a profit by charging high prices to insurance is not the same as “just caring about profits.” While there are people in any industry who just do their jobs for the money, biotech tends to attract people motivated by the desire to punch a disease in the face. We all have our personal reasons. I invite journalists, anyone who teaches public health policy, and all our elected federal representatives to tour the labs in Kendall Square, Fenway, and Watertown and speak with the many physicians and scientists who work in our industry about what motivates them. You’ll hear stories of parents, grandparents, children, and friends lost to or suffering from diseases. You’ll hear stories of hope for those still suffering and waiting anxiously for their cure. You’ll meet people working with purpose. And once our representatives discover a sense of pride in their biopharma constituents, maybe they could bring colleagues from other states to our robust life-sciences ecosystem to meet them so that someday no one in Washington will think that the work of creating new medicines to prevent hospitalizations is less virtuous than building a new hospital wing to accommodate more beds. Our economic, medical, and personal future depends on medicines we have yet to invent. Let’s make sure they’re discovered, developed, and even manufactured right here in Massachusetts. And let’s make sure that our representatives in Washington are fighting for Massachusetts instead of against us. The work of the MA-rketing Coalition And so, to resolve the Massachusetts Paradox, let’s all of us in the biopharma industry and adjacent sectors (e.g., banking, consulting, accounting, and law) join together to operationalize and fund a MA-rketing Coalition that will do the necessary R&D to figure out how to inspire Massachusetts voters to be proud of the part of their economy that we represent. What is the wording we should use? What are the stories? What are the insights people need to gain to realize that there is far more to be proud of than to resent about the biopharma industry? Massachusetts is our laboratory for working all that out. Once we sort out what works, we can apply those same messages and communication tools in other states that host biopharma jobs. And even when states don’t have biopharma jobs, they still have a lot to look forward to from America’s biomedical leadership and therefore should remain informed and supportive of their home team. So resolving the Massachusetts Paradox is just a stepping stone to resolving the American biotech paradox. And no state has more to gain from leading that resolution than Massachusetts. Some of the seeds for the MA-rketing Coalition can be found in the videos and articles produced and hosted by No Patient Left Behind. How can new medicines be affordable? Here’s an animation. What are medicines worth? Here’s another animation; it’s our answer to ICER & NICE. What is Regular Joe’s contribution to the quest to defeat cancer? Here’s a message from innovators with a thank you to every member of the public. An awareness campaign of the injustices of out-of-pocket costs? Here you go. A video to make the point that there’s no justice in copays for chemo. It’s here. A cartoon that reflects that absurdity? An NPLB Fellow created one. Do drug companies invent medicines or just sell what the NIH invents? Another video. Hate that innovators are called “manufacturers”? Us too. We launched the #CalltheInventors campaign to spread the word that we’re called Inventors and to remind patients to call for assistance with coverage. It includes an AI that can pull up the patient assistance contact info for every drug. The list goes on. NPLB is experimenting with different ways of engaging the public to turn haters, skeptics, and everyone else into fans. It’s only beginning to do the hard work of resolving the Massachusetts Paradox. Ultimately, it’s going to take more ideas, more people, and money to deliver the best researched messages to the masses. If you’re with a biotech company, investment firm, investment bank, or any organization that has a business interest in preserving our innovation framework, then consider joining in on the NPLB effort. If you have creative marcomms people, let them pitch in – their skills are valuable. While all pharmas (necessarily and somewhat incessantly) run DTC ads hoping to reach patients who need to know about the availability of a new medicine, only a few pharmas have done anything to engage everyone in the value and wonder of the innovation process itself. We all must. Let’s capture our most exciting stories Consider our immune system. The responsibility of defending our bodies from harm is not limited to T cells, B cells, and other such cells we think of as being a part of the immune system. Every cell is actively involved through antigen presentation and cytokine production. You can’t outsource self-preservation. It’s a community effort; all hands on deck. No bystanders. Similarly, our industry has to get away from thinking that a few lobbying groups can stand in for the rest of us when it comes to keeping America pro-innovation. We all have a role to play. I think that what’s within the power of any small company and certainly any large one is to document its stories and present its characters. So if you’re with a biotech company, think of an exciting experiment that will yield data within six months. Identify the people who understand this experiment and have a stake in its conduct and outcome. These can include your scientists, executives, board members, investors, clinical investigators, patient advocates, patients, bankers, lawyers, etc. And then talk to them, on camera. Talk to them well before the data readout. Talk to them when those data are almost ready. Film their reactions when they find out if the trial was a success or a failure or somewhere in between. We’ve created a chat agent that can help you create questions for your interviews and even help with scripts. Try it out, below. You can also enter this prompt into chatGPT to turn it into a useful agent to guide you through this project. Then grab your smart phone (or a real video camera if you’re ambitious). Your production values don’t need to be high. Getting lighting and audio right takes real skill, but AI video editing is making it easier to fix such things later. So focus on just getting authentic answers on camera. Think of this like capturing the excitement of football players ahead of the Super Bowl. Your future audience wants to feel your excitement and anxiety. If it’s not exciting for you, it’s not exciting for them. On the day that you’ll get the data, train cameras on the faces of every member of the team as they see it. Capture the moment. Capture the joy. Capture the despair. Interview people about what comes next. Do the same with others outside your company who know and care about your work. Interview the parents of scientists. Interview their teachers even. Show that all of America is connected to the people on the front lines of fighting disease on behalf of everyone. Hold on to all your footage. Whether you ever let it be seen will be up to you and your lawyers. Having this footage means that you now have the option to participate in the MA-rketing Coalition by contributing your stories. We have a very rare example of this kind of storytelling thanks to Eli Lilly and the filmmaker James Kreach, who made the documentary film Turning Point (free to watch on Youtube) about Lilly’s solanezumab Alzheimer’s program (and captured the failure of its Phase 3 trial on the faces of all the people involved). I hope someday there’s a sequel about the development of donanemab (Kisunla), the Alzheimer’s drug Lilly launched in 2024 that clearly stands on the learnings from solanezumab. If hundreds of companies did this each year, that would create a large inventory of stories that the MA-rketing Coalition could draw on to stitch together compelling narratives of how we collectively make progress, narratives that include success stories and the more common failures. Maybe BIO can include a session at its conferences on how to best conduct and film these interviews, in between sessions on how to conduct clinical trials and VC panels on fundraising. As we bring the audience into a world of multiple competing teams in which all strive but ultimately only a few see their dreams realized while most others’ dreams are dashed, they will see people who get knocked down and later get up and win. Success is sweeter when you’ve tasted the bitterness of failure. Maybe the audience won’t hate us for the necessarily high prices insurance pays for our successfully developed medicines if they see what went into grasping those victories. It’s not as if the biopharma industry hasn’t told the public about how risky R&D is, but I’m talking about showing the public, not telling. Let the audience experience the risks and consequences of failure. Once you have the audience’s attention, it will be very important to resolve their doubts. They think we profit from people’s pain and charge excessive prices; that has to be resolved in people’s minds before they will ever become our fans. My main quibble with Turning Point is that it didn’t resolve this question of cost and affordability. If you watch the movie, compare how it grapples with this point with how No Patient Left Behind addresses it in this video featuring a cast of executives working on treatments for Alzheimer’s. The answer I wish came through is that Lilly is counting on insurance to make their medicines affordable to all who need them, and if insurance charges excessive out-of-pocket costs to someone who then struggles to get a medicine they need, then we need to reform insurance. After all, we’ve all prepaid for proper care via our premiums; no one should be made to pay twice when they fall sick, especially not more than they can afford. Insurance that does that isn’t proper insurance. And there is no innovation without proper insurance. So until everyone has the insurance they need, Lilly will do all it legally can to assist patients with access. As inventors of these miracles, we can’t imagine not doing that. But as a society, we can’t expect inventors to both create medicines and pay for them. So if you watch Turning Point, as I hope you do, compare that answer with how the movie handles questions of costs and affordability and do it better in your movie. Ultimately, contributing to this storytelling requires an individual commitment. If you’re a scientist at a company, you have to win your colleagues over to join you. Share this article. Get together to watch Turning Point. Maybe it’s a board decision, in which case win over the board. Lawyers will no doubt have a view on what can be shared so as not to give away intellectual property or create any legal liability. But just know that the world’s largest pharma – Eli Lilly – found a way to get to “yes.” Lilly’s CEO Dave Ricks participated. If Lilly, which employs a lot of lawyers, can get to “yes,” then any company should find its own way to “yes.” It’s just a matter of how. If your lawyers say “no” instead of showing you how, consider getting new lawyers (the legal team at RA Capital is more than happy to recommend great lawyers). Because if everyone hides behind the excuse that their lawyers said “no,” then we won’t ever solve the Massachusetts Paradox. Multi-media, Omni-channel All our stories can be packaged into many delivery vehicles. Different audiences will prefer different media. As with gene therapy, it doesn’t matter how good your payload is if cells don’t take up the vector. In trying to connect with our audience, every form of storytelling via any available distribution channel is fair game. The Novo Nordisk story came through powerfully to a wide audience in a four-hour episode of the Acquired podcast. It was accompanied by a fascinating hour-long interview with Dr. Lotte Knudsen, who led the invention of Ozempic at Novo and won the highly prestigious Lasker prize for her work. It’s hard to come away disliking Novo after listening to those podcasts. Some stories could be told in full-length documentaries like Turning Point. Members of the MA-rketing Coalition could create YouTube channels with episodes. Maybe patient advocacy groups feature videos on their websites and create YouTube channels. Maybe medical schools will feature some clips in their classes. Maybe Hollywood will option some stories to create fictionalized dramas, like the movie Extraordinary Measures based on John Crowley’s remarkable journey: “True story of a father on a crusade to cure his children's fatal disease.” a person holding a card Not all such efforts will come out as well as intended. Turning Point saw little distribution and doesn’t even have a rating or reviews on Rotten Tomatoes (though I agree with Alzheimer’s Weekly, which called it “gripping”). Extraordinary Measures got a 29% splat with reviews dismissing it as a made-for-tv tear jerker. That’s okay. At least these movies exist. We can learn from them and do better. As an industry, we’re used to trying and failing before breaking through with a win. Contagion, about a pandemic that may as well have been a playbook for COVID and Operation Warp Speed, lionized vaccine developers, scored 85%, and was widely distributed. Our stories can be commercially successful. One of my friends has suggested that we need a comedy like HBO’s Silicon Valley centered on biotech startup culture. Yes! And having our stories and concepts worked into existing shows can allow us to reach wide, established audiences. Remember the South Park episode on Ozempic in which Cartman “navigates the American health system” (i.e., the absurdities of insurance)? Seeing how John Stewart mischaracterized Medicare Negotiation shows how far we have to go to make our case to public figures with audiences. But imagine if he really understood the biotech social contract, the value of medicines, and the role of insurance in making innovation possible and affordable, and showed us how to teach those concepts effectively to America. The idea I can’t get out of my head is creating a docuseries modeled on Netflix’s Drive to Survive, which has dramatically expanded the fan base for F1 racing. Every season, the producers focus on a few teams and characters so that the audience connects with them deeply, episode after episode, experiences the despair of a near loss and the thrill of a long-sought victory, and stays with them through the season to some climax. Yes, you learn about the physics of tire friction, aerodynamics, engine design, and fuel management, but it’s character-driven. Ultimately, we come to appreciate that this is more than just some guys driving around and around. Here’s a pitch for a biotech show that draws the comparison to Drive to Survive. Relentless: The Quest for Cures In Formula 1, every season is a race against time, money, and fate. Drive to Survive pulls you inside the chaos, where bold designs meet brutal reality and only a few make it to the podium. In Relentless, the race is for treatments and cures. Multiple companies, each chasing the same disease. Each unveiling their “machine” – a carefully and expertly crafted drug candidate entering a Phase 2 trial – built on years of science and ambition. Early signals spark hope. Midway struggles test belief. Rivalries simmer. Whispers spread. And then…the readout. For some, it’s triumph: proof their idea works, a shot at changing medical practice forever and saving lives! For others, the dream shatters in an instant. Winners. Losers. Glory. Heartbreak. But the race continues. Disease waits for no one. I imagine Relentless running forever. In twenty years, let’s be on Season 20. Had we been doing this for the last twenty years, there would have been a few seasons that featured hepatitis C, culminating in cures; immuno-oncology, culminating in cures; CAR-T therapies, culminating in cures. Today, we could talk about obesity, autoimmune diseases, Alzheimer’s, and many other diseases where we are making progress. The race to develop a multi-cancer early detection blood test is just heating up. Longevity as a theme – parsing science from fiction – should be engaging to many. We’ve seen the public on the edge of its seat, hungry for news from our trials. Remember Covid? Maybe we can reclaim some of that interest with better storytelling. While there’s no one disease that unites us all quite like Covid did for a brief period, there are huge audiences with personal stakes in the quests to cure so many other diseases. Heroes vs Villains Every story has to have an antagonist. Who’s the bad guy in our story? It’s not death. We all have to die. So our mission can’t be a quest for immortality at all costs, but rather is a quest for greater healthspan and death with grace and without pain, in our homes surrounded by mostly younger loved ones. Diseases, particularly chronic ones, saddle us with pain and disability and/or shorten our lives. Disease is the real enemy. And if everything in our healthcare system worked as well as it could, disease would be the only real antagonist in our stories. But our healthcare system hardly works as it should. There are some other bad guys. Every time a person is railroaded by their insurance plan – denied access to an appropriate treatment based on some fine print or bureaucratic heartlessness – we’ve got ourselves a bad guy. Maybe not the person on the front lines who has to follow internal policy and issue a denial, but somewhere up the chain of command we’ll find someone who doesn’t give a shit. Propublica did a remarkable job of capturing just such a story in their coverage of a patient denied CAR-T therapy due to the scheming of his insurance plan’s Chief Medical Officer, Dr. James Forshee, and the plan’s lawyers. Tell me you wouldn’t click on that to find out. You come away from the story recognizing that there are some really cruel people out there. The insurance plan, Priority Health, later reversed course. Hopefully the way that Forshee comes across in this article serves as a warning and deterrent to everyone. But lest you think I’m suggesting that all insurance executives are bad guys, that same Propublica story introduced us to Dr. John Fox, the Associate CMO, whom a physician described as “the conscience of the company.” Dr. Fox objected to what his boss was trying to do and helped blow the whistle in this article. I know there are many other good people within insurance who cheer for innovation and are eager to expand coverage to include newly launched medicines that can improve people’s lives. They take pride in helping people get access to the medicines that can cure them. They see enabling proper care as their job. They would make for compelling characters in our stories too, to show audiences that it’s possible for insurance plans to do good. So insurance itself isn’t the boss-level villain of our story. Even the bad guys need not be true villains if they show some remorse; hopefully insurance executives portrayed as bad guys in one episode might be reformed and join the good guys. Our goal should be for all insurance to earn its place alongside the innovator heroes in our stories. After all, there really is no innovation without effective insurance. So for the biopharma industry to be a protagonist in a compelling story between good and evil, disease is really the only arch-nemesis we need. Intermission If you are jazzed by the potential of the MA-rketing Campaign and think you might want to get involved – or simply interested in what it would take to pull this off – please read on. You’ll gain a deeper understanding of the concepts we all need to align on, the potential costs of the campaign, and metrics of success. In a hurry? Skip to the final section below for a rousing finale! Part 4: Aligning on core concepts and believing in ourselves Before we can truly effectively address the public’s antipathy towards our industry, we have to resolve the mis-understanding and even self-hatred within our own ranks. On insurance as the key to affordability: If a scientist working on a diabetes medicine were asked why patients can’t afford insulin, what would they say? I’ve probed this. Some say that they think drug companies charge too much. Some say R&D is expensive. The effective, correct answer speaks to insurance design and the injustice of out-of-pocket costs, but that’s not what most people reach for. So we have some work to do inside our tent. On the term “recoup”: I hear CEOs talk about how companies have to charge high enough prices that investors can “recoup” their investment. Recoup? So an investor puts $10,000 into a biotech company, they should get $10,000 back if the company is successful? That’s not very compelling. None of us should ever use the term “recoup” since no one ever invests with the goal of just getting their money back; the goal of investment is to generate a return on investment, which means making a profit. When you say “recoup” you invite Bernie Sanders to operationalize “recoup” by making you account for how much money actually went into inventing your drug and then demanding that you make only as much money as it takes to “recoup” that investment. No profits for anyone. On “me-too” drugs: It’s quite common to hear from people in biotech that our industry develops too many me-too drugs. I think that’s a slippery slope; one person’s me-too is another person’s Humira, Lipitor, Sovaldi, or Keytruda. I think when society signals that it values having a solution to a disease and scores of innovators and their investors jump into a race to compete for the prize, that’s awesome. My team visualizes these races in our TechAtlas maps and it's absolutely inspiring because you come away with the confidence that there’s no nut we can’t crack. And society should celebrate having multiple drugs in a class; that gives PBMs leverage to negotiate lower net prices. Besides, undifferentiated late entrants tend not to generate nearly as high returns as earlier ones. As long as it’s true that you have to be either first and/or best to win the biggest prize, then the market is incentivizing all the right competitive behaviors. Investors who back undifferentiated late entrants will soon enough learn their lesson and do less of that. Ultimately, very little money is wasted relearning this lesson. On the link between drug prices and where companies are located: Another example of a common misunderstanding is the idea that the US has to pay high prices to have a US-based biopharma industry. The inverse of that is when people say that the US can pay lower prices because Europe pays a lot less and still has a vibrant biopharma industry. Neither of these views are correct; where a company is based and where products are sold need not have anything to do with one another. GSK and AstraZeneca, based in the UK, don’t innovate for the UK market. Novo Nordisk is based in Denmark, which pays much less for Ozempic than the US. Like drug companies all over the world, they focus on the US market. It’s the US market for medicines that drives investment in R&D and innovation jobs wherever those jobs happen to be. All countries that host biopharma companies have a stake in making sure that the US continues to value medicines as we do. Yet, like a scorpion on a turtle’s back, they sting the US with their cost-effectiveness analyses, claiming that medicines aren’t worth the prices the US pays. If the US were to agree with them and pass price controls, their free ride would end. There are Europeans who understand this, even ones who work at NICE, but vilifying pharma is politically expedient and, besides, surely the US won’t ever pass price controls on medicines, right? I’ve written on whether the European scorpion can hold its sting and how to end international freeriding (hint: not Most Favored Nation policy). These can be useful references for talking points and useful analogies for members of the MA-rketing Coalition who find their stories require tackling these issues. On DTC advertising: DTC advertising is another controversial issue generating frequent misalignment among even those in our own industry. One argument goes that other countries don’t allow DTC ads and our industry wouldn’t be as hated if we didn’t push them on the American public. I take the other side of that argument. In a world where doctors are overworked and many pride themselves on not letting themselves be contaminated by meeting with sales reps, how are patients supposed to learn that a product even exists? As an investor, how can I count on doctors to learn about a new drug once it launches? Who better than self-interested patients to march into doctors’ offices to do exactly what the ads urge: talk to your doctors to see if Drug X is right for you. When a dozen patients come in asking about the same drug, that doctor will have to learn about it. They don’t have to prescribe it. They can explain when it’s not the right treatment option. Sure, it might annoy a doctor to have to explain it, but keeping people ignorant is not the solution. And with insurance likely requiring a prior authorization to ensure that the drug is right for that patient, odds are few people are going to get that medicine who don’t need it. A good drug, if people know about it, will inspire them to fight for coverage. That fight ultimately determines the breadth and ease of coverage and where the net price settles out. That’s how value is calculated by the US marketplace and how prices end up being negotiated. This marketplace couldn’t do its work without knowledge of the product. As a result of DTC ads, maybe lots of patients who do need a particular drug will be correctly diagnosed and treated with it. That’s not over-utilitization. That’s appropriate utilization. That’s a good thing. Keeping people in the dark results in under-utilization. That other countries ban DTC ads is entirely consistent with their desire to spend as little as possible on healthcare. They use price controls to keep prices down and then ban DTC ads to keep patients as ignorant about the availability of a new medicine as possible. Since spending is a function of price and volume, other countries minimize both. If the US banned DTC ads, then as an investor I would have less confidence that a successfully developed drug would ramp to the peak sales that my market models suggest should be possible. I’ll know there are many eligible patients to treat, but I won’t be as confident that those patients will realize that they are eligible for the new medicine. So DTC ads are important for spurring innovation, especially for underdiagnosed diseases. In my discussions with people who oppose DTC ads, these arguments tend to lead them to moderate their view but still voice some discontent with these ads. For them, it still boils down to how insipid they are. I’m not a marketing expert and won’t wade into judging whether industry’s DTC ads are any good. Presumably companies live or die by their marketing and have every incentive to do the best job they can to create effective ads. But I certainly agree that DTC ads of our approved medicines are not the way to turn the broader public into our fans. I would love to see even a few percent of our industry’s collective DTC budget (over $10B) turned towards the MA-rketing Coalition’s work. On pitting Biotech vs Pharma: Some in our community might think that we should rescue biotech by throwing pharma under the bus by emphasizing the distinction between the virtues of small biotech and the villany of big bad pharma. That won’t work. In casting pharma or large companies as the bad guys, the small biotech community would be ingesting poison. That’s because validating the public’s antipathy for pharma will result in anti-pharma policies, all of which, like the pill penalty, undercut small biotech just the same. Let’s say that the US passed price controls on new drugs that only applied to drugs launched by big pharma. A small company would be exempt, but its acquisition would be off the table since the drug would instantly be subject to price controls the moment it was acquired by a big pharma. That would force all small companies to fully develop and launch their own drugs. And while it would be nice if every small company could launch its own drugs, that would create gross inefficiencies. Without a small company being able to negotiate using a portfolio of drugs, PBMs would eat them for lunch in any competitive drug class. It’s not for nothing that Celgene got big due to Revlimid, a drug that was in a class of its own for a long time. Same for Biogen, Vertex, and ArgenX. Meanwhile, small companies that launch into competitive classes get squeezed and typically opt to get acquired. And the fact is that pharmas are not the bad guys. They innovate, too. However expedient it would be for biotech to distance itself from pharma, the fact is that we are largely the same. Sure, big pharma has portfolios of older drugs and therefore more opportunity to engage in all kinds of clever tactics to squeeze rents from them, stretching or even violating the biotech social contract that says that drugs should go generic without undue delay. But that’s not unique to pharma. Turing was a small company when it price-jacked Daraprim. What makes us good or bad is the degree to which we abide by the intent of the biotech social contract. Our jobs are to compete like hell with one another to create new medicines that will then go generic without undue delay. We should inform patients and physicians about them without stretching the truth. We can try to charge whatever the market will bear but we must not collude with competitors to fix prices. If we do our part, then better health flows from our work. When we invent new medicines, we are all like builders who build homes and look forward to being paid a finite mortgage by home owners. Once a drug goes generic, it’s like society has paid off the mortgage and the medicine becomes an inexpensive public good. So if those of us who agree that all medicines should go generic without undue delay are Builders, then Landlords are those who would like to exploit every trick in the book not to innovate but to just milk an aging drug for more profit, functionally turning what should be a finite mortgage into an extended rent stream. So the tension in our industry is between Builders and Landlords, not small biotech and big pharma. We want the Builder-nature of both to remain while removing the temptation of rent-seeking. I discussed this in a podcast with Luke Timmerman back in 2020 that he titled “The Battle for the Soul of Biopharma”. Ending Landlord behavior would indeed reveal that big pharma – now exclusively rewarded for innovation – is every bit as virtuous as any small biotech company. If there were a law that ensured that all drugs that failed to go generic on-time would be subjected to the backstop of a price control, that would do the trick. I called it Contractual Genericization in my book, and it kicked in 15 years after a drug launched if it hadn’t gone generic. In 2022, Congress called it Medicare Negotiation and you know how that goes. The treatment of biologics is close enough to the right policy to end rent-seeking without removing incentives to innovate. The nine-year pill penalty represents destructive overreach that turns Builders away. On orphan vs all other diseases: Some companies and investors have argued in favor of exempting rare disease treatments from the IRA's Medicare "negotiation" program. There are two problems with that thinking. The first problem is that exempting rare diseases throws other diseases under the bus. It’s unseemly to have orphan disease advocates saying “me me me” as if those suffering more common yet still unaddressed diseases such as Alzheimer’s, Parkinson’s, and heart disease aren’t worthy of having their needs recognized. This isn’t Sophie’s choice. We don’t have to prioritize one disease over another. Incentives for all innovation can be restored with a 9-13 fix to the IRA’s pill penalty. The second problem is that exempting rare disease drugs risks creating forever-monopolies for drugs that are difficult to genericize (or biosimilarize), like gene therapies. If one wants to incentivize orphan disease development, the solution is not to exempt them from the biotech social contract’s rule that all drugs must go generic without undue delay. It’s to increase confidence that insurance will continue to properly cover novel rare disease treatments at necessarily-high market prices during those first 13 years. Because the One, Big Beautiful Bill already granted an expansion of the orphan Medicare Negotiation exemption, one might wonder why I’m bringing this up. It’s because there may be future price control proposals that require our community to rise up in protest, and I hope that we don’t once again see different people splintering off to advocate for narrow exemptions just for their disease or modality. On insurance being bad if it doesn’t cover a medicine: Some people think that insurance is bad if it doesn’t cover a drug. But they don’t actually say “no” to a drug; they so “no” to paying a particular price for a drug. And since innovators are the ones setting that price, we should no more vilify a plan for saying no to that price than they should vilify us for charging what we are charging. It’s everyone else who stands in judgement. And they don’t just judge with their words. They judge with their money. If people think that an insurance plan is bad, they switch. It’s not immediate, but over a few years, insurance companies that misjudge what people value lose profits. The fact that competing insurance plans can each choose for themselves what to cover at what price and people who buy insurance (even if acting collectively through employers) choose which insurance plan to sign up for at what price (premiums vary) means that there is a marketplace of countless choices that negotiates with innovators on the prices and volumes (i.e., revenues) they earn with their inventions. If all insurance plans were forced by law to cover every drug, then there wouldn’t be a market to set prices and any company with a unique drug (i.e., the only one in its class) could charge any price. Trikafta is a miracle drug for patients with cystic fibrosis, but if it were priced at $1B/patient, it would cost the entire US GDP. Even if a company claimed to be “reasonable” and charged only $300k, as Vertex does, nothing would stop activist investors from taking it over and raising the drug’s price. So the end result of forcing insurance to cover everything regardless of price … is that the government would then actually be justified in dictating prices. That’s called central planning and it’s the destructive opposite of the market-based innovation economy we have now. Central planning is innovation kryptonite; as stressful as it may be to win coverage from insurance for a novel medicine in the US healthcare marketplace, that’s preferable to being subject to the pricing whim of the government. So to preserve our market-based approach, we must accept that insurance doesn’t have to cover every drug. They should cover whatever treatments they think will allow them to compete effectively with all the other plans that people have to choose from. They don’t have to pay for Trikafta at $300k, but nearly all plans do because, at that price, which is similar to the price of many other orphan disease drugs, the cost per person is modest enough that it’s not worth the bad press they would get if word got out that they denied that treatment to someone with cystic fibrosis (besides, at that price the drug is actually cost-saving over the long run, but that’s another story). At much higher prices, some plans might refuse to cover it and believe that, because the price would be above the market price for similar medicines, the public might side with the plan against Vertex. If plans that refused to cover Trikafta didn’t lose business, more plans would decide not to cover Trikafta. So the ultimate judges are all Americans who influence which plans get their premium checks (either directly or indirectly through their employers). It’s not a perfect market in that individuals can’t switch easily, but it works well enough on the scale of 1-3 years, which is about how long we consider a drug’s launch phase. When a new drug launches, plans might drag their feet on coverage for a few months or even a year, but if they wait much longer than that, most people will have the chance to vote with their feet and switch if they think a plan is heartless. What makes an insurance plan bad is false advertising. They should be honest about what they cover. Charging people insurance premiums while claiming to cover all the medicines that would be considered standard of care and then, when someone falls ill, demanding out-of-pocket costs from them that they can’t quite afford before actually providing the medicine is a repudiation of insurance itself. That’s what I’m calling false advertising. Plans should be honest about what they will and won’t make affordable to members so they can be judged in the renewal marketplace. And so we need to shine a light on who makes what decisions and allow the public to hold the right people accountable for what the public considers the wrong decisions. We can show them the blood and sweat and time that went into making a medicine and the value of that medicine and let them judge for themselves if they think a plan has erred in not covering it. On the need for skin-in-the-game: A lot of people assume that copays are necessary to ensure that patients have skin-in-the-game and that no one over-uses medicines they don’t really need. But they assume that without really thinking about what most medicines are. Sure, there are GLP-1s that a lot of people want. But what about insulin. Or chemo? Who fakes cancer to score chemo? The reality is that insurance isn’t true insurance if people pay premiums for years and then discover, upon needing a treatment, that they can’t afford the deductible or copayments for a covered medicine. And while reducing OOP costs might increase premiums (likely by only a few percent), it’s better that there be a marketplace with prices that reflect the cost of proper insurance than that the marketplace be contaminated with cheaper fake insurance that screws you later when you’re vulnerable. America is wealthy enough to figure out how to afford proper insurance that doesn’t lie to anyone. Congress banned plans from discriminating on the basis of pre-existing conditions and it can cap out-of-pocket costs. In fact, the IRA did that for Medicare plans. When I’ve spoken with people who actually run insurance plans, they acknowledge that it’s entirely possible to design plans with low/no OOP costs but felt that these plans would only be competitive in a marketplace where everyone had to play by the same rules. If some insurance company designed a plan with no OOP costs but higher premiums, a lot of healthy people would opt for lower-premium skimpy plans and then switch to a plan with higher premiums and better coverage if they got sick; that would result in adverse selection that would destroy the insurance market. In fact, the only thing that stops that from happening now is that most people get insurance through their company and companies tend to have a mix of young/healthy people and older people with health conditions and therefore have to offer a plan that works for the latter, functionally forcing the young/healthy employees to pay for that same plan. That’s a good thing because for an insurance plan to cover older, sicker people, it needs lots of younger, healthier people to pay premiums. If young people get away with paying little for skimpy insurance, then insurance for everyone else is unaffordable, a problem called “adverse selection” which is toxic to the whole concept of insurance. Some people think that insurance needs to have different copay tiers in order to be able to negotiate with competing drug companies for who will have favorable tier placement on the formulary. Actually, plans can charge low/no out-of-pocket costs and still steer patients using prior authorizations and step edits to a preferred drug. So they still can play companies off one another in a competitive class without out-of-pockets. And speaking of prior authorizations, they aren’t inherently bad. But they should be honest. Excessive prior authorization friction is yet another trick plans use to deter patients from getting a treatment the plan claims it covers and to deter doctors from even trying to prescribe it. If a plan claims to cover a medicine but requires a prior authorization to confirm that the drug is right for a patient, then it should make the prior authorization process as simple as needed to get the necessary information. Don’t burden a doctor with data entry when the information is already in the patient’s medical record. Let’s not compromise truth for engagement I share these examples of fairly complex and commonly misunderstood concepts to illustrate that the MA-rketing Coalition has to have a robust intellectual core that ensures that we don’t sacrifice truth, facts, and the first principles of innovation and insurance in our effort to tell engaging stories. We have to be both engaging and intellectually rigorous. We can’t have characters saying “recoup” or claiming that the US has more drug companies because it pays higher prices. It’s easy to get the words wrong and accidentally make a facile argument. But words matter. If we mistakenly teach the wrong ideas, we’ll eventually find ourselves fending off yet more misinformed policy. Activists holding signs protesting pharma: "Pharma Greed Kills", "Pills Cost Pennies, Greed Costs Lives" AP Photo AP Photo Part 5: How we’ll know MA-rketing is working Anti-innovation policies including price controls on novel medicines (i.e., Medicare Negotiation earlier than 13 years post launch, Most Favored Nation) are supported by most of our Massachusetts reps and most everyone in Washington. That’s how we know we have a problem. So the way we’ll know that the MA-rketing campaign is working is if we see some more Massachusetts representatives speaking out against these policies and proposing constructive ones, like the Epic bill to fix the pill penalty and insurance reforms to lower OOP costs. Ultimately, success will be measured by legislative wins that restore and maintain the incentives that have allowed the US to lead the world in biomedical innovation and make sure insurance does the job we expect it to when we pay premiums. But we can’t expect that outcome until voters themselves shift how they think about the drug industry. There are surrogate markers of that shift all around us. You’ll know the MA-rketing campaign is working when you read an article in the Boston Globe or even the New York Times that talks about a drug’s high price and see more comments posted from readers bringing up the role of insurance instead of accusing drug companies of being greedy. In time, you’ll see journalists covering the drug industry spend more time on insurance design; when they talk about the price of a drug, they will clarify “price to whom” and distinguish the price companies charge to insurance from the price that insurance imposes on patients. Even when the MA-rketing campaign is working, it won’t work right away. If we can rely on industry rankings of public trust or favor, we’ll see our ranking rise. Right now, according to Gallup, we’re at rock bottom, below the federal government. We have a long climb ahead of us. Even if we make progress, from time to time there will still be flawed policy proposals that we’ll need to fend off. But if we’re successful with our campaign, then the flares should become less frequent and easier to fend off. This is not a one-time campaign that we stop once our industry gets to a high enough ranking in a Gallup poll. It’s meant to be a part of our ecosystem’s long-term strategy. Much like the immune system, you don’t shut it down when you’re healthy. It’s what keeps you healthy. Consider how even something as self-affirming as vaccines go through cycles, like we’re in now, when the public’s trust wanes. Vaccines have worked so well keeping measles off our minds that some people started to think that we didn’t need vaccines. The same thing could happen with all medicines. If America reformed insurance so that everyone had insurance with low/no out-of-pocket costs and could therefore afford covered medicines, one might think that people would no longer be outraged about list prices. They would stop blaming drug companies for people not being able to afford medicines. And if magically other countries paid more for medicines so they were no longer freeriding on America’s market-based prices, Americans would no longer have cause to feel like they are being collectively ripped off. That’s all nice to imagine. Were that to come to pass, maybe there would no longer be calls for price controls. But who is to say that the next Turing- or Valeant-style price-jacking of an old drug won’t trigger an anaphylactic reaction against our industry that spills over into some flawed anti-innovation policy (which is a good reason to offer up policies that would prevent bad actors from acting badly)? No industry is perfect. Someone associated with our industry will piss off the public in the future. It takes a long time to build trust, and one bad act to break it, and the bad stuff makes the headlines. One has to continuously preserve a good reputation and project that reputation through effective marketing. And when we lose trust, we have to have the ability to win it back. So longer term, the efficacy of the MA-rketing Coalition might be judged not only by how much our industry is loved but how quickly we are able to restore that love when it wavers. We’re reminded to be grateful for our immune system by how quickly we recover from an infection. Part 6: What will MA-rketing cost? Early on, we’ll need to spend some money on what’s called message testing and optimization. Once we figure out what works, we’ll shift to content development/production and then the bigger bucks will likely go to distribution and promotion. The hardest part of any campaign these days is punching through the noise to actually get your message in front of people. Content The cost of generating content is highly variable. The good news is that anyone with a phone in their pocket can make a video. The cost of making engaging content is rapidly falling thanks to AI, but you have to have the grit to learn. Hiring people to do this work starts to cost money. A small film production crew to shoot and edit a short video might cost tens of thousands. Producing a documentary film could be a few hundred thousand or costs a few million. A season of a docuseries on Netflix might be $10M+. These numbers are tiny compared to the ones we are used to in drug development. Even a $300M feature-length Hollywood film like F1 is affordable compared to the $300B per year our industry risks on R&D, not that such massive undertakings make any sense for the MA-rketing campaign at this time. Paul Revere's Midnight Ride Paul Revere's Midnight Ride Paul Revere's Midnight Ride Distribution To get our messages out, all of us have a role to play, even if it’s just using our power to like, repost, comment, and share the stories that align with our core messaging. Ask your friends, networks, and advocates to help. Tag them in posts. Engagement puts platform algorithms to work for us. And when we notify each other of the stories we are telling, the coalition can help amplify and aggregate everyone’s great work. We can hope that something we produce will go viral and that news outlets will choose to cover our stories without us having to pay for airtime. But hope is not a strategy. Trust is earned through visibility, repetition, and familiarity. We have to plan for a steady level of spending and activity. And that takes money. One of the advantages of focusing our initial efforts on Massachusetts is that paying for distribution in a single geography will be less expensive than a national campaign. No Patient Left Behind will be devoting a fair bit of effort to the MA-rketing campaign and fielding a team to help small companies package their stories and secure distribution. For now, we’re aiming to get to a sustained annual budget on the order of $10M to create and distribute content. I think it’s very affordable. What can we afford? Consider how to think about the value our industry has at stake. Total valuation of whole biopharma industry: >$5T Total annual R&D spend of all companies large and small: ~$300B Total valuation of just development-stage public companies: >$300B Total assets under management (AUM) of just biotech specialists: >$100B Total annual DTC spending by pharma: >$10B Total annual spending by PhRMA: >$400M Total annual spending by BIO: >$90M Total value of biotech financings per year: >$100B Total banker fees per year (assuming 6% fee on just $50B of equity financings): $3B As an insurance policy against the tail risk of destructive policy, spending merely a few tens of millions per year experimenting to figure out what works in Massachusetts and then spending a few hundred million per year nationally is readily affordable relative to what’s at stake and the size of various pools of capital and streams of cash flow. A basis point (0.01%) of our industry’s total valuation would be >$500M per year. Just 1% of DTC budgets would be >$100M/year. A basis point of specialists’ AUM would be $10M. A basis point of just the valuation of development-stage public companies yields $30M. A basis point of all money raised per year yields $10M. Just 1% of what bankers make from financings would yield $30M. Even the Massachusetts state government has about $10M in its budget for communications. However you look at it, our industry and Massachusetts itself can afford to fund a MA-rketing campaign to resolve the Massachusetts Paradox. Arguably, neither can afford not to run such a campaign. Part 7: Commitment, for the long run I think resolving the Massachusetts Paradox is the most important near- and long-term goal that biopharma advocacy can set itself to. I’m committed to this campaign. As a scientist and investor but also just being a human being with family, friends, and colleagues I care about, I want to see innovation continue. There’s so much we can do if we preserve a policy framework that inspires the world’s investors to keep biotech in their portfolios. If we can’t get Massachusetts voters to rate biopharma highly and support policies that make innovation possible (i.e., solve affordability with insurance reform to lower out-of-pocket costs, not price controls), then how can we invest with confidence? The sky isn’t falling right now. The point is to make sure it doesn’t ever fall. When we invest in a preclinical program in 2025, we’re betting there won’t be price controls at any point before at least 2045, after which we assume our drug will go generic anyways. Hated as much as our industry is (ranked dead last!), and given the rate at which each successful drug launch erodes the public’s tolerance, can anyone be confident that there won’t be worse price controls than the pill penalty over the next twenty years unless we fight like hell to win the public’s trust and love? And that starts at home. We have to solve the Massachusetts Paradox. Once we do that and fuel a sustained pro-innovation marketing effort to keep the public onside, we can have confidence in sound policy for decades into the future. MA-rketing is a prudent insurance policy against a clear and growing tail risk of anti-innovation policy. It’s existential for our industry and vital for our state. I hope you see a role for yourself in this. Join me, RA Capital, No Patient Left Behind, and others who have signed on below to make the MA-rketing Coalition a reality. Sign up for next steps here.