Just after Emma Kleck turned 26, she started looking up flights to Canada.

Kleck, who has type 1 diabetes, knew she’d be paying a hefty sum each year for the test strips, body sensors, and insulin vials she needs to manage her disease once she switched from her parents’ insurance to the high-deductible plan her job offers. She was determined to see if she could find a cheaper option.

In the U.S., insulin costs have more than tripled in recent years. A single vial of Novo Nordisk’s Novolog, the insulin Kleck takes daily, costs roughly $300 per vial. Kleck uses a little over a vial per month.

Those rising prices have had disastrous, and sometimes deadly, impacts for people with type 1 diabetes, 1 in 4 of whom have reported they’ve rationed insulin to save money. It’s particularly hard for young people like Kleck who aren’t making as much money or offered as robust an insurance plan as older Americans. Alec Smith, a 26-year-old restaurant manager from Minnesota, died from rationing insulin less than one month after aging off of his mother’s insurance.

In Canada, however, insulin costs less than $50 per vial. And increasingly, people seeking cheaper insulin are flying north from all over the U.S. to stock up.

In December, Kleck booked the cheapest flight she could from her home in Santa Cruz, Calif., 1000 miles north to Vancouver. The Right Care Alliance, a Massachusetts-based advocacy group, supplied her with a list of reputable Canadian pharmacies that it keeps at the ready for those planning their own pilgrimage. She traveled with photographer Monique Jaques, who documented their trip.

Emma Klek - TD1 journey
Emma onboard the flight to Seattle from her home in California.
Emma Klek - TD1 journey
While traveling, Emma’s blood sugar often goes low. Emma checks her blood sugar in the car before driving to the border.

Kleck’s trip underscores the lengths to which people with diabetes will go to save on this lifesaving drug. But it also highlights the toll diabetes itself takes on patients, costs aside. The mundane inconveniences of waiting in long lines, lugging heavy suitcases, and being stuck in an airplane seat can mean waves of blood sugar highs and lows that require constant vigilance.

That’s true for even Kleck, whose diabetes management is about as automated as it can be.

She has, mounted on her skin, a wireless glucose monitor that keeps a watchful eye on her blood sugar levels, along with another sensor that delivers her insulin through the skin without the need for constant injections. The two communicate via an app on her phone that the Food and Drug Administration hasn’t yet approved. If her monitor detects high blood sugar, her app will send a signal to her insulin pump, which will then automatically deliver her a specific amount of insulin — all without her intervention.

Emma Klek - TD1 journey
Emma enters a pharmacy where she has ordered Novolog, the insulin she takes.
Emma Klek - TD1 journey
Emma pays for her insulin in Canada, a move she hopes will save her thousands of dollars.

But Kleck needs to prepare for the worst: She carries a teal pouch emblazoned with “All My Diabetes Shit.” At last check, it included three back-up insulin pump patches, a handful of syringes, a vial of insulin, lip balm, a blood glucose meter, test strips, a lancing device, a packet of gooey electrolytes, a handful of used test strips — along with her car registration, her insurance card, and a credit card. Throughout the trip Kleck also kept close watch on a vial of glucagon, an emergency injection that first responders can use to revive patients who have a diabetic emergency like a seizure.

Then there’s the tattoo sprawled across her left forearm meant to alert first responders of her diabetes in the event she’s found unresponsive. On her 18th birthday, the tattoo replaced the medical alert bracelet her parents made her wear throughout her childhood.

Emma Klek - TD1 journey
Emma waits in the line of cars entering the U.S. at the Blaine, Wash., land border leaving Canada. Her tattoo is both practical — it replaces a medical alert bracelet — and a signal of her status as a type 1 diabetes activist.
Emma Klek - TD1 journey
Emma prepares to leave her Vancouver Airbnb the day after purchasing her insulin. Here she is hacking her glucose monitor in an attempt to make it last longer, a method she learned online. Emma’s smartwatch keeps tabs on her blood sugar while she is traveling. She also travels with a supply of juice, energy gels, and extra syringes in case of emergency.

Americans crossing into Canada for cheaper drugs isn’t altogether new. Droves of seniors made national news in the early 2000s when they organized busload after busload to Canada. Presidential hopeful Sen. Bernie Sanders (I-Vt.) rode along with activists with type 1 diabetes on a similar pilgrimage last year.

Sensing a business opportunity, pharmacies, like the one Kleck visited, have popped up along the Canadian border. They provide a safer alternative to online pharmacies, some of which have been plagued by counterfeit drugs.

But Kleck admits she was a bit skeptical when she pulled up to a dilapidated strip mall on the outskirts of Vancouver only to find a run-down pharmacy nestled between an adult shop, a fried chicken joint, and a marijuana dispensary.

Emma Klek - TD1 journey
Emma heads to work after an early-morning flight back to San Jose. She is a nurse practitioner at a women’s clinic.

When she finally got the nerve to walk in, she was greeted by an operation dedicated almost exclusively to serving the U.S. market. Packaging supplies and even dry ice, meant to keep insulin at a safe temperature while it travels through the mail, lined the walls.

She walked out of the pharmacy with 10 vials of Canada’s version of Novolog, named NovoRapid, at a cost of $459. The same insulin would have cost her $2,570 in the U.S., according to Kleck’s calculations.

It’s technically illegal to import unapproved drugs from Canada, but regulators typically don’t object to patients eager to save a few bucks while on vacation. FDA’s website states that it “typically does not object” to people importing less than a three-month supply of a drug for personal use.

The question she got, however, she was unprepared for: “How much cheaper was the insulin?” the guard inquired.

After a quick back and forth, they were free to go, insulin in hand.

Emma Klek - TD1 journey
Emma unpacks her insulin at home.
Emma Klek - TD1 journey
Emma and her dog, Fleur, head to work. Fleur is a fully trained early alert canine that goes everywhere with Emma. She is able to let Emma know if her blood sugar gets too low.

Kleck’s insulin now sits in her refrigerator. Despite the literal highs and lows of living with type 1 diabetes, she knows she won’t have to worry about paying for her insulin — at least for the next 10 months.

When her stockpile runs out, she won’t be forking over $300 to her local Walgreens. Instead, she plans to test out her new favorite pharmacy’s mail-order service.

“It’s going to be so easy,” Kleck said.

  • Bernie is certainly not in the pocket of Big Pharma or the profit making insurance companies! As the author of the Medicare for All Bill in the US Senate, he did “say” something about the ridiculously high prices of drugs which includes insulin. Medicare for All will provide patients with ALL medically necessary drugs and treatment and this means diabetics would get their insulin easily. I am so sorry to hear of the death of your daughter and it brings tears to my eyes also —- and anger and also the energy to keep working for Medicare for All which will make healthcare comprehensive and affordable and put patients before profits. Our current healthcare industrial complex is in crisis as healthcare becomes more and more unaffordable.

  • Thank you so much for this posting. I wish that the candidates for our presidential race would speak up about this. If Bernie knows about this why is he not saying something, is he in the pocket of Big Pharma just like the JDRF is. My daughter died from Ketoacidosis rationing her insulin to try to make it to her paycheck which was coming right after Christmas in 1918. She had been diabetic for 18+ years, was a nurse, and did not make it. She died on Christmas day. You no doubt know that more people die every year in the USA from diabetic problems than in auto accidents and gun violence combined. Over 70,000 last year, more people than died as American soldiers in the ten years of war in Viet Nam.

  • An added factoid, it still costs about $8.00-$10.00 a vial to manufacture the preferred insulins (I say preferred because they are the most effective available). When first brought to market, the list price was $25.00 per vial. I have receipts from 2016 that show list price of $1,255 for 3 vials – do the math.

  • I am confident that no one who is opposed to Medicare for All has to make these choice for themselves or their children.

    If you or your children need medication and would die without it would you then choose Medicare for All.

    • Kris: You are making this too simple. People who oppose “Medicare for All” do so because they have a much better benefit from their employer, which they would have to give up if Bernie and his disciples have their way. That better insurance is part of their compensation, in place of higher wages. Robbing the middle class of their benefits is not going to help the overall situation.

    • Yes, you may have a really well-paying job and medical insurance until you or your family members get really, cancer, Parkinson’s, MS, etc then you will likely be singled out and laid off or fired so the company no longer has to pay the extra premiums. I know this to be true as friends and neighbors have had this happen.
      Plus my Mother used to work for a very large corporation and was instructed several times over the years she worked there to single out people who cost of health insurance were too high and find a reason to fire them.

      I sincerely hope that does not happen to you or your family. And I hope you develop more compassion for others who are not as fortunate as you are at this moment in time.

  • Also patients get educated and ask your Physician to prescribe one of the insulins that are available near where you are, Mexico or Canada (as not all insulins brands are available in Mexico and Canada). Once you are stabilized on that insulin and are comfortable in calibrating the dose, go to Mexico/Canada and get your insulin at lower cost.

  • Technically, Glucagon is not used ‘to revive patients who have a diabetic emergency like a seizure. Glucagon is used to quickly counteract an hypoglycemic (low blood sugar) episode to prevent the hypoglycemia from progressing to a medical emergency (which can include seizures & loss of consciousness).

  • Nice warm tone to this article, besides a really good topic to write about during the Democratic primaries.

  • “Kleck’s insulin now sits in her freezer. ”

    No it does not! It’s in her fridge (as shown in the picture) You cannot store insulin in a freezer because frozen insulin is destroyed insulin. Please fix this statement.

  • This is such a fabulous article on so many levels. It reveals the personal struggles of most Americans trying to juggle their present and future needless overcharges for their medications. Thanks for a moving and enlightening expose of one woman’s take-charge attitude to issues that most think they cannot control. It was truly inspiring!

    I would love to see Mr. Florko examine the pitfalls and personal odysseys of lyme patients (which I am). Keep up the good work!

    • Excellent book on Lyme disease came out recently: “Bitten” by Kris Newby.
      More price issues with the testing described.

  • Great article exposing the many challenges for those of us with Type 1. FYI, in the 2nd last paragraph you said the insulin is in her freezer. I don’t think you can safely freeze insulin and the picture above the para shows Emma putting it in her fridge.

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