President-elect Donald Trump’s incoming administration could try to remove fluoride from drinking water, according to Robert F. Kennedy Jr.

Kennedy, who was tapped last week by Trump to lead the Department of Health and Human Services, called fluoride an “industrial waste” and linked it to cancer and other diseases and disorders while campaigning for Trump.

“On January 20, the Trump White House will advise all U.S. water systems to remove fluoride from public water. Fluoride is an industrial waste associated with arthritis, bone fractures, bone cancer, IQ loss, neurodevelopmental disorders, and thyroid disease,” Kennedy wrote Nov. 2 on X. Kennedy linked to a video from an attorney who recently successfully sued the Environmental Protection Agency to take additional measures to regulate fluoride in drinking water.

Kennedy, who has long advocated ending water fluoridation, persisted with his pledge following Trump’s election win. When asked before the election whether his administration would remove fluoride from drinking water, Trump said, “Well, I haven’t talked to him about it yet, but it sounds OK to me. You know it’s possible.”

Kennedy is an influential vaccine skeptic whose campaign of conspiracy theories earned PolitiFact’s 2023 “Lie of the Year.”

Longtime research has found that adding fluoride to U.S. drinking water is a safe way to boost children’s oral health. Since 2015, the recommended level in the U.S. has been 0.7 milligrams per liter. Public health organizations, including the American Dental Association, the American Academy of Pediatrics, and the Centers for Disease Control and Prevention, support the practice.

Recent studies, however, have shown possible links between fluoride and bone problems and children’s IQs, particularly when fluoride is above the U.S. recommended levels.

“There is evidence that fluoride exposure has been associated with the diseases [and] disorders that RFK listed, but with caveats,” said Ashley Malin, who is an assistant professor in the University of Florida’s Epidemiology Department and has studied fluoride’s effects in pregnant women.

Malin referred to studies showing that higher fluoride exposure, particularly during pregnancy, is associated with reduced child IQ, and that prenatal exposure also is linked to decreased intellectual functioning and executive function. For high exposure in pregnancy, the studies showed symptoms associated with other neurobehavioral issues, such as attention-deficit/hyperactivity disorder.

However, many of these studies took place in countries other than the U.S. and looked at fluoride in drinking water at sometimes twice the United States’ recommended level. Also, some of the other ailments that Kennedy listed, such as an association with bone cancer, have less robust evidence and need more study.

“Aside from fluoride’s impacts on neurodevelopment, I think that there is more that we don’t know about health effects of low-level fluoride exposure than what we do know, particularly for adult health outcomes,” Malin said.

David Bellinger, a Harvard Medical School neurology professor and professor in Harvard School of Public Health’s Environmental Health Department, said the risk-benefit calculation of added fluoride differs depending on whether typical fluoride exposure levels cause health problems, or if problems occur only when recommended levels are exceeded.

“In toxicology, ‘the dose makes the poison’ is a long-standing principle,” he said. “So a general statement that fluoride is associated with diseases X, Y, and Z is not very helpful unless the dose that might be responsible is specified.”

PolitiFact contacted Kennedy through his Children’s Health Defense organization but received no reply. The organization sued PolitiFact and Meta related to a 2020 fact check. That lawsuit was dismissed by a federal court. The dismissal was upheld on appeal, and the case is pending a possible appeal to the U.S. Supreme Court.

What Is Fluoride and What Are Its Benefits?

Fluoride is a mineral naturally occurring in soil, water, and some foods that helps prevent tooth decay and cavities. It strengthens tooth enamel that acid from bacteria, plaque, and sugar can wear away.

Water fluoridation has been happening in the U.S. since 1945.

The federal Public Health Service first recommended fluoridation of tap water in 1962, but the decision still lies with states and municipalities. Around 72% of the U.S. population, or about 209 million people, had access to fluoridated water in 2022, the CDC reported. Fluoride also has been added to oral care products such as toothpaste and mouth rinse.

In 2015, U.S. health officials lowered the recommended amount of fluoride in drinking water to 0.7 milligrams per liter, saying a higher level was less necessary given other sources of fluoride, and that the lowered amount would still help protect teeth without staining them.

Pediatric dentists note that applying fluoride with toothpaste and rinses is beneficial, but small amounts circulating in the body via water consumption helps younger children who still have their baby teeth, because it can benefit the developing permanent teeth.

The American Dental Association says studies have shown that fluoride in community water systems prevents at least 25% of tooth decay in children and adults and that “for more than 75 years, the best scientific evidence has consistently shown that fluoridation is safe and effective.”

The association says on its website: “It’s similar to fortifying other foods and beverages — for example, fortifying salt with iodine, milk with vitamin D, orange juice with calcium, and bread with folic acid.”

According to the CDC, health experts and scientists from the U.S. and other countries have so far “not found convincing scientific evidence linking community water fluoridation with any potential adverse health effect or systemic disorder such as an increased risk for cancer, Down syndrome, heart disease, osteoporosis and bone fracture, immune disorders, low intelligence, renal disorders, Alzheimer’s disease, or allergic reactions.”

The agency says risks of water fluoridation are limited to dental fluorosis, which can alter dental enamel and cause white flecks, spots, lines, or brown stains on the teeth when too much fluoride is consumed.

Do Studies Show Fluoride Posing Any Other Risks?

Some studies have said that excess fluoride exposure, often at higher levels than the recommended U.S. limit, can harm infants’ and young children’s developing brains and that higher levels of fluoride exposure during pregnancy were associated with declines in children’s IQs.

A study published in May that Malin led with University of Southern California and Indiana University researchers suggested that fluoride exposure during pregnancy was linked to an increased risk of childhood neurobehavioral problems and said more studies were “urgently needed to understand and mitigate the impacts in the entire U.S. population.”

Experts noted prenatal fluoride exposure is most strongly linked to children’s IQ loss, and said timing of fluoride consumption might need to be considered when making recommendations.

A federal review of dozens of studies published in August by the Department of Health and Human Services’ National Toxicology Program concluded that higher levels of fluoride exposure were linked to lower IQs in children. But the report was based primarily on studies in countries such as Canada, China, India, Iran, Mexico, and Pakistan and involved fluoride levels at or above 1.5 milligrams per liter, twice the recommended U.S. limit. The authors said more research is needed to understand whether lower exposure has any adverse effects.

In the report, researchers said they found no evidence that fluoride exposure adversely affected adult cognition.

Bellinger, of Harvard, pointed to the review as an example of how the amount of fluoride matters. He noted how researchers concluded that a very small percentage of people in the U.S. are exposed to levels that correlate with IQ loss.

“Second, the fact that there are now multiple pathways of exposure to fluoride besides fluoridated water (toothpaste and other dental products, etc.) makes it really difficult to attribute a particular adverse effect to the fluoride added to the water,” he wrote via email. “It is the cumulative exposure from all sources that contribute to any adverse health effects.”

In September, a federal judge ordered the Environmental Protection Agency to further regulate fluoride in drinking water because of the potential risk that higher levels could affect children’s intellectual development.

U.S. District Judge Edward Chen wrote that the court’s finding didn’t “conclude with certainty that fluoridated water is injurious to public health,” saying it’s unclear whether the amount of fluoride typically added to water is causing children’s IQs to drop. But he wrote that there was enough risk to warrant investigation and that the EPA must act to further regulate it. The ruling did not specify what actions the agency should take, and the EPA is reviewing the decision.

After the ruling, the American Association of Pediatrics issued a statement that fluoride in drinking water is safe for children and said the policy is based on a robust foundation of evidence.

Besides dental fluorosis, experts say that fluoride exposure over many years above the U.S. recommended amount can cause skeletal fluorosis, a rare condition that causes weaker bones, stiffness, and joint pain. Although the Public Health Service recommends a fluoride concentration of 0.7 milligrams per liter for community water systems, the EPA, under the Safe Drinking Water Act, sets enforceable standards for drinking-water quality. Currently, to prevent skeletal fluorosis, the EPA requires that water systems not exceed 4 milligrams of fluoride per liter of water.

Malin said she and her research team are investigating a potential link between fluoride and bone fractures. She said that although several studies have found high fluoride exposure associated with increased risk of bone fractures, and some have linked fluoride with thyroid disease, rigorous, U.S.-based studies haven’t been done.

The CDC concluded that recent research found no link between cancer risk and high levels of fluoride in drinking water.

The American Cancer Society reviewed a possible link between water fluoridation and cancer risk. An organization spokesperson pointed PolitiFact to its review and said it has no data showing a definitive answer.

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This article first appeared on KFF Health News and is republished here under a Creative Commons license.

If you went “anywhere in the world,” you could get a prescription filled for 40% to 60% less than it costs in the U.S.

Joe Biden on Feb. 22, 2024, at a campaign reception

It’s well documented that Americans pay high prices for health care. But do they pay double or more for prescriptions compared with the rest of the world? President Joe Biden said they did.

“If I put you on Air Force One with me, and you have a prescription — no matter what it’s for, minor or major — and I flew you to Toronto or flew to London or flew you to Brazil or flew you anywhere in the world, I can get you that prescription filled for somewhere between 40 to 60% less than it costs here,” Biden said Feb. 22 at a campaign reception in California.

He followed up by touting provisions in the 2022 Inflation Reduction Act to lower drug prices, including capping insulin at $35 a month for Medicare enrollees and limiting older Americans’ out-of-pocket prescription spending to $2,000 a year starting in 2025. The law also authorized Medicare to negotiate prices directly with drug companies for 10 prescription drugs, a list that will expand over time.

Research has consistently found that, overall, U.S. prescription drug prices are significantly higher, sometimes two to four times as high, compared with prices in other high-income industrialized countries. Unbranded generic drugs are an exception and are typically cheaper in the U.S. compared with other countries. (Branded generics, a different category, are close to breaking even with other countries.)

However, such factors as country-specific pricing, confidential rebates, and other discounts can obscure actual prices, making comparisons harder.

“The available evidence suggests that the U.S., on average, has higher prices for prescription drugs, and that’s particularly true for brand-name drugs,” said Cynthia Cox, director of the Peterson-KFF Health System Tracker, which tracks trends and issues affecting U.S. health care system performance. “Americans also have relatively high out-of-pocket spending on prescription drugs, compared to people in similarly large and wealthy nations.”

Andrew Mulcahy, a senior health economist at Rand Corp., a nonpartisan research organization, agreed that Biden’s overall sentiment is on target but ignores some complexities.

He said price comparisons his team has conducted reflect the amounts wholesalers pay manufacturers for their drugs, which can differ sharply from prices consumers and their drug plans pay.

“In many of those other countries, [patients] pay nothing,” Mulcahy said. “So I think that’s part of the complication here when we talk about prices; there are so many different drugs, prices, and systems at work.”

What International Drug Pricing Comparisons Show

A 2024 Rand study that Mulcahy led found that, across all drugs, U.S. prices were 2.78 times as high as prices in 33 other countries, based on 2022 data. The report evaluated most countries in the Organization for Economic Co-operation and Development, or OECD, a group of 38 advanced, industrialized nations.

The gap was largest for brand-name drugs, the study found, with U.S. prices averaging 4.22 times as high as those in the studied nations. After adjusting for manufacturer-funded rebates, U.S. prices for brand-name drugs remained more than triple those in other countries.

The U.S. pays less for one prescription category: unbranded, generic drugs, which are about 33% less than in other studied countries. These types of drugs account for about 90% of filled prescriptions in the U.S., yet make up only one-fifth of overall prescription spending.

“The analysis used manufacturer gross prices for drugs because net prices — the amounts ultimately retained by manufacturers after negotiated rebates and other discounts are applied — are not systematically available,” a news release about the report said.

People with health insurance pay prices that include both markups and discounts negotiated with insurers. Uninsured people may pay a pharmacy’s “usual and customary” price — which tends to be higher than net prices paid by others — or a lower amount using a manufacturer discount program. But many of these adjustments are confidential, making it hard to quantify how they affect net prices.In 2021, the Government Accountability Office released an analysis of prices of 20 brand-name drugs in the U.S., Canada, Australia, and France. The study found that retail prices were more than two to four times as high as in the U.S.Like Rand, the agency adjusted for rebates and other price concessions for its U.S. estimate, but the other countries’ estimates reflected gross prices without potential discounts.

“As a result, the actual differences between U.S. prices and those of the other countries were likely larger than GAO estimates,” the report said.

Another analysis by the Peterson-KFF Health System Tracker that Cox co-authored compared the prices of seven brand-name drugs in the U.S., Germany, the Netherlands, and the United Kingdom, and found that some U.S. prices were two to four times as high. For unbranded, generic drugs, the price gaps were smaller.

“Despite the fact that the U.S. pays less for generic drugs and Americans appear to use more generic drugs than people in other countries, this did not offset the higher prices paid for brand-name drugs,” Cox said.

The Peterson-KFF report, using 2019 OECD data, found that the U.S. spent about $1,126 per person on prescription medicines, higher than any peer nation, with comparable countries spending $552. This includes spending by insurers and out-of-pocket consumer costs.

“Private and public insurance programs cover a similar share of prescription medicine spending in the U.S. compared to peer nations,” the report noted. “However, the steep costs in the U.S. still contribute to high U.S. health care spending and are passed on to Americans in the form of higher premiums and taxpayer-funded public programs.”

Why Is the US Such an Outlier on Drug Pricing?

The U.S. has much more limited price negotiation with drug manufacturers; other countries often rely on a single regulatory body to determine whether prices are acceptable and negotiate accordingly. Many nations conduct public cost-benefit analyses on new drugs, comparing them with others on the market. If those studies find the cost is too high, or the health benefit too low, they’ll reject the drug application. Some countries also set pricing controls

In the U.S., negotiations involve smaller government programs and thousands of separate private health plans, lowering the bargaining power.

“It’s complicated. Everything in health care costs more here, not just [prescriptions],” said Joseph Antos, a senior fellow at the American Enterprise Institute, a conservative-leaning think tank, in an email interview. Although the government’s new Medicare drug negotiation is the United States’ first attempt to set drug prices, Antos noted that U.S. drug price negotiation still doesn’t operate as price-setting for prescriptions in Europe does because it’s limited to a few drugs and doesn’t apply to Medicaid or private insurance.Drug patents and exclusivity is another factor keeping U.S. drug prices higher, experts said, as U.S. pharmaceutical companies have amassed patents to prevent generic competitors from bringing cheaper versions to market.Drug companies have also argued that high prices reflect research and development costs. Without higher consumer prices to offset research costs, the companies say, new medicines wouldn’t be discovered or brought to market. But recent studies haven’t supported that.

One 2023 study found that from 1999 to 2018, the world’s largest 15 biopharmaceutical companies spent more on selling and general and administrative activities, which include marketing, than on research and development. The study also said most new medicines developed during this period offered little to no clinical benefit over existing treatments.

Our Ruling

Biden said, if you went “anywhere in the world,” you could get a prescription filled for 40% to 60% less than it costs in the U.S.

He exaggerated by saying “anywhere in the world,” but for comparable high-income, industrialized countries, he’s mostly on target.Research has consistently shown that Americans pay significantly higher prices overall for prescription medication, averaging between two times to four times as high, depending on the study. The U.S. pays less for unbranded, generic drugs, but those lower prices don’t offset the higher prices paid for brand-name drugs, researchers said.

Factors including country-specific pricing, confidential rebates. and other discounts also obscure true consumer prices, making comparisons difficult.

Biden’s statement is accurate but needs clarification and additional information. We rate it Mostly True.

PolitiFact copy chief Matthew Crowley contributed to this report.

Our sources:

WhiteHouse.gov, remarks by President Joe Biden at a Campaign Reception | Los Altos Hills, California, Feb. 22, 2024

PolitiFact, “Are US Prescription Drug Prices 10 Times Higher Than Those in Other Nations? Only Sometimes,” May 18, 2023

Rand Corp., “International Prescription Drug Price Comparisons,” Feb. 1, 2024

Rand Corp., “Prescription Drug Prices in the U.S. Are 2.78 Times Those in Other Countries,” Feb. 1, 2024

Peterson-KFF Health System Tracker, “How Do Prescription Drug Costs in the United States Compare to Other Countries?“

Peter G. Peterson Foundation, “How Much Does the United States Spend on Prescription Drugs Compared With Other Countries?” Nov. 7, 2022

Government Accountability Office, “Prescription Drugs: U.S. Prices for Selected Brand Drugs Were Higher on Average Than Prices in Australia, Canada, and France,” March 29, 2021

Commonwealth Fund, “How Prices for the First 10 Drugs Up for U.S. Medicare Price Negotiations Compare Internationally,” Jan. 4, 2024

C-SPAN, “Health Care Advocates and Researchers Testify on Prescription Drug Prices,” Feb. 8, 2024

Center for American Progress, “Following the Money: Untangling U.S. Prescription Drug Financing,” Oct. 12, 2023

Congressional Budget Office, “Prescription Drugs: Spending, Use and Prices,” January 2022

The New York Times, “Six Reasons Drug Prices Are So High in the U.S.,” Jan. 17, 2024

The Commonwealth Fund, “Paying for Prescription Drugs Around the World: Why Is the U.S. an Outlier?” Oct. 5, 2017

Forbes, “U.S. Drug Prices Sky-High in International Comparison,” July 22, 2022

The BMJ, “High Drug Prices Are Not Justified by Industry’s Spending on Research and Development,” February 2023

Wired, “Big Pharma Says Drug Prices Reflect R&D Cost. Researchers Call BS,” Oct. 13, 2022

Email interview, Kelly Scully, spokesperson for the White House, Feb. 26-27, 2024

Phone interview, Andrew Mulcahy, senior health economist at Rand Corp., Feb. 27, 2024

Email interview, Michelle Mello, law and health policy professor at Stanford University, Feb. 27, 2024

Email interview, Joseph Antos, senior fellow at the American Enterprise Institute, Feb. 26, 2024

Email interview, Cynthia Cox, director of the Peterson-KFF Health System Tracker at KFF, Feb. 27, 2024

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