In today’s world, access to affordable and quality healthcare often hinges on the principles of free trade and open markets. Just as Napoleon once attempted to revolutionize commerce with his vision of free ports, modern markets—including healthcare systems—depend on removing restrictive barriers to enhance access and drive innovation. The parallels between Napoleon’s economic reforms and today’s challenges within pharmacy benefit management (PBM) underscore the enduring value of open, competitive systems that benefit consumers.
Napoleon’s Vision: Free Ports and Open Access
Napoleon’s economic policies, while shaped by war and politics, introduced the concept of free ports—designated trade hubs where duties were reduced or eliminated, and commerce flowed freely. Cities like Genoa, Venice, and Ancona were strategically transformed into free ports, fostering trade and economic growth.
The idea was simple: by reducing bureaucratic and economic barriers, Napoleon aimed to establish hubs of commerce, improve access to goods, and stimulate growth. Despite his eventual political downfall, his vision planted the seeds for economic liberalization that would resurface in Europe and Latin America in the decades that followed.
This policy didn’t just open markets; it highlighted how reforms based on free access could revitalize stagnating systems and make essential goods available to underserved populations.
Free Trade in Healthcare: A Modern Parallel
Napoleon’s free ports offer a valuable historical lens through which to view modern PBM systems. In healthcare, access to medications—particularly life-saving treatments like insulin—is often hindered by closed markets, high costs, and fragmented systems. Pharmacy benefit managers, when structured effectively, act as intermediaries to negotiate fair prices and ensure open access to critical treatments.
In an ideal PBM model, principles of free trade align with healthcare goals:
- Open Markets: Encouraging competition among manufacturers to reduce costs.
- Enhanced Access: Removing restrictive barriers to ensure all patients can obtain necessary medications.
- Cost Efficiency: Passing negotiated savings on to patients, just as free ports reduced trade burdens to stimulate local economies.
Breaking Barriers: Expanding Access
Napoleon’s refusal to grant Marseille the status of a free port may seem contradictory, but it reflected his belief in a strategic approach to liberalization. By concentrating reforms in key locations, he aimed to maximize economic output while retaining control. Similarly, in healthcare, strategic policies around PBMs can optimize access without destabilizing the system. This is the formulary management mindset. Some manufacturers intend to exploit the consumer base by bringing high cost, low clinical value drug products to market. The due diligence of clinicians at health plans and PBMs is paramount. They’re afforded powerful governance measures to allocate resources as efficiently as possible.
Consider the current struggles surrounding insulin pricing. When markets are closed—controlled by a small number of manufacturers or intermediaries—patients suffer from inflated costs and limited access. By opening markets through transparency and competition, PBMs can act as the modern free ports of healthcare, enabling patients to access affordable treatments.
Global Impact and Innovation
Napoleon’s economic experiments rippled across continents, influencing free trade debates in Latin America and Europe for decades. In healthcare, the lesson is clear: closed systems stifle progress, while open competition drives innovation and broader access.
As countries grapple with rising medication costs, PBMs and policymakers must adopt strategies rooted in Napoleon’s vision:
- Deregulate Trade Barriers: Allow biosimilars and generics to compete more freely.
- Leverage Strategic Hubs: Use decentralized systems to reduce inefficiencies and distribute savings. Specialty pharmacy models are capitalizing on this.
- Ensure Fair Pricing: Like free ports balanced trade benefits, PBMs must ensure negotiated savings directly reach patients. Without pass-through, the patients aren’t ever seeing the lowest cost the market can offer.
Conclusion: The Future of Open Markets
Napoleon’s free ports were more than economic reforms; they were a statement of belief in open access and the power of free trade to drive progress. Today, the healthcare industry—particularly within PBM systems—faces a similar crossroads. By embracing open markets, encouraging competition, and prioritizing access, we can transform how patients access life-saving medications.
In Napoleon’s words, “Trade would be free once peace was achieved.” I’m not sure I entirely agree with the order of operations here though. Make trade free, then the peace will follow.
References
- Delogu, Giulia. “Free Ports, Free Trade, Freedom: Napoleon’s Manifold Legacy in Institutions and Images.” From the Napoleonic Empire to the Age of Empire, War, Culture and Society, 1750–1850, edited by T. Dodman and A. Lignereux, Springer Nature, 2023, pp. 127–150. https://doi.org/10.1007/978-3-031-15996-1_7.
