WASHINGTON — Although 42 states allow the recycling of unused medications as a way to get prescriptions to people who can’t afford them, about 35 million Americans a year still can’t afford to buy their medications because the state programs are just getting off the ground and many have complicated rules for recycling.

Meanwhile, $2 billion worth of unused medications no longer needed by patients are destroyed each year by pharmacies, hospitals and nursing homes, according to a University of Chicago study.

Despite implementation of the Affordable Care Act, having insurance doesn’t mitigate the high costs of drugs, especially for those with low incomes. In addition, a number of people do not have enough coverage for many chronic, complicated conditions that require expensive and multiple drugs.

On the supply side, drugs often go unused because health care providers and pharmacies must have a constant stockpile of medications, patients heal without using their full prescriptions or they switch medicine midway through treatment.

“Every step in the supply stream has a little bit of excess medicine,” says George Wang, co-founder of SIRUM, a nonprofit drug recycling organization. “The little bit of excess medicine in what is a $300 billion pharmaceutical industry in the U.S. happens to be a lot of excess medicine.”

According to the National Conference of State Legislatures, 42 states have laws allowing for the establishment of drug recycling programs.

“Getting those laws in place and to a point where it allows for an efficient process has taken a lot of time,” Wang said. “Each of these laws is state by state, it’s patchwork. It seems arbitrary that you can’t cross a state line.”

Nursing homes, assisted care living facilities, hospitals, pharmacies, wholesalers and manufacturers can donate excess medications to safety-net clinics and pharmacies. Individuals cannot participate in the system– the exchange of the medication is strictly between licensed entities to ensure quality control.

These laws provide guidelines such as donated drugs cannot be expired, there needs to be participation by a state-licensed pharmacist or pharmacy in the verification and distribution process, and each patient who is to receive a drug must have a valid prescription form. Some states have more restrictive laws, covering only certain drugs, while others are more all-encompassing, even including over-the-counter medications.

Priscilla VanderVeer, deputy vice president of communications for the Pharmaceutical Research and Manufacturers of America, said PHRMA doesn’t track whether individual member companies participate in recycling programs and it doesn’t have a set policy.

“The biggest challenge is that you can’t guarantee the quality of the drug, the ingredients in the drug and how the drug may have been stored,” she said. “Our companies cannot control that when it’s taken out of the closed distribution system and put into these other programs.”

The complicated logistics required to make donations efficient and safe are a stumbling block that some nonprofits like SIRUM are trying to address, according to Wang.

In December 2015, another co-founder of SIRUM, Kiah Williams, won the first annual Forbes Under 30 $1 Million Change the World Competition. The company received recognition for its technology that connects unopened, unexpired surplus medication to people in need through facilitating donations between licensed entities.

“It’s a win-win for all of the parties,” said Wang. “The people donating to us don’t have to pay for all the medicine to be destroyed and then we’re able to take it off their hands and give it to someone who needs it.”

Because the process occurs state by state, this has slowed efforts as well as resulted in medication remaining within confining borders.

Wang and others have suggested a federal law would make drug recycling easier and address the problem of not being able to donate medications across state lines.

“If you can verify that those medications are still potent, this could be good on a national level and could ultimately result in reducing health care costs,” says Georges Benjamin, executive director of the American Public Health Association. “However, sometimes recycling things is more costly than throwing away and recreating the drug. But if it can be done cheaper, and you could do it in a way so the system is efficient to run to get the verified medication repackaged, why not?”

Benjamin suggested developing agreements between bordering states as a practical first step. Areas such as metropolitan DC, which extends beyond the capital and into Maryland and Virginia, or the tri-state region of New York, New Jersey and Connecticut, often have people who cross state borders to work and receive medical care.

“That would make a lot of sense to do,” added Benjamin.

Wang said the progress in getting the final states on board with drug recycling laws and programs would be a way to force a federal effort. An effort underway in Illinois, where a team is working with SIRUM to draft legislation, provides a template for all states.

“Illinois is not cookie cutter, but in a way Illinois can mirror any state,” “says Levi Moore, government affairs consultant at the Hektoen Institute of Medicine, a nonprofit based in Chicago that manages health care and medical grants. “You have super urban, big suburban, middle America central and then just pure rural areas. We’re looking at this to be a statewide effort. To show that this bill does impact every county in the state, that it does benefit every county in the state, strengthens it.”

Raising awareness by having laws enacted and expanding initiatives is vital to making sure the programs remain successful and continue to grow, according to Wang.

“In five years, we hope this is the standard in the health care industry,” he said. “You don’t even think twice that of course you recycle these medicines, it’s natural. Just like you would recycle a coat, you should be recycling any unused pill.”