Court Opinion

ID: 9781690
Source: CourtListenerOpinion
Date Created: 2023-08-30 17:09:06.969297+00
Date Added: 2024-06-11T12:13:09.306287
License: Public Domain

LIPEZ, Circuit Judge,
concurring in the judgment.
The Maine statute at issue here, like the New Hampshire law we considered in IMS Health Inc. v. Ayotte, 550 F.3d 42 (1st Cir.2008), is a creative effort to meet escalating concerns about the high cost of prescription drugs and the way they are marketed. Other states have passed or considered similar legislation. See, e.g., IMS Health Inc. v. Sorrell, 631 F.Supp.2d 434, 446 (D.Vt.2009) (addressing a Vermont statute);35 IMS Health Corp. v. Rowe, 532 F.Supp.2d 153, 180 n. 41 (D.Me.2008) (noting initiatives in other states); Michael Heesters, Comment, An Assault on the Business of Pharmaceutical Data Mining, 11 U. Pa. J. Bus. L. 789, 791 (2009) (same). The two statutes *33that we have reviewed, along with Vermont’s, are aimed at restricting the messages that may be presented by pharmaceutical detailers to prescribers. Because these provisions have the purpose and effect of regulating the content of speech, their compatibility with the First Amendment is a challenging issue that inevitably will be considered by the Supreme Court.
The statutes specifically seek to prevent pharmaceutical detailers from using the prescribing histories of individual health care professionals in their marketing approach to prescribers. In the view of the States, these individualized sales pitches result in the over-prescription of high-priced, brand-name drugs, thereby needlessly increasing public expenditures on prescription drugs and, at times, harming patient health.36 In an effort to minimize the First Amendment implications of their content-based goal, Maine and New Hampshire attempted to cut off access to the prescribing information at its source. Hence, the statutes prohibit the sale, transfer or other dissemination of prescriber-identifiable information among pharmacies and other data-collecting entities for marketing purposes, but impose no direct limitation on the drug companies or sales people who do the actual marketing.37 The States insist that the laws thus regulate conduct, not protected speech.
As I explained in Ayotte, it begs reality to characterize these laws as regulations of conduct. Maine’s statute, like New Hampshire’s, must be judged for what it is — a restriction on protected speech subject to the demands of the First Amendment. That view has been validated by the Supreme Court’s recent decision in United States v. Stevens, — U.S.—, 130 S.Ct. 1577, 176 L.Ed.2d 435 (2010). See infra Section II. However, as construed by the State, Maine’s law also has a substantial ripple effect beyond Maine’s borders that requires review under the dormant Commerce Clause. By shifting the statute’s focus away from the activity considered harmful — the detailers’ interactions with prescribers in Maine — to the earlier sales of the data, the Legislature in practical effect targeted transactions that occur primarily outside the State.
I agree with the majority that this out-of-state reach is not fatal. I write separately, however, to highlight the unusual relationship between the First Amendment and Commerce Clause issues. Indeed, after examining the law’s impact on interstate commerce, I conclude that the First Amendment is the appropriate battleground for constitutional analysis as these cases move through the courts.
I. The First Amendment-Commerce Clause Dance
As a reflection of the analytic difficulties posed by New Hampshire’s and Maine’s *34laws on the use, sale and other dissemination of prescriber-identifiable data, their provisions are baffling even to their proponents. New Hampshire’s Attorney General asserted in Ayotte that the law should be construed to govern only in-state transactions, see 550 F.3d at 63-64, an interpretation that renders the statute largely irrelevant because the transfers of data the statute purports to restrict occur almost entirely out-of-state. Maine, by contrast, concedes that its similarly worded provision reaches out-of-state activity. At oral argument, however, when pressed about the statute’s reach, the State’s counsel asserted that section 1711-E(2-A) would cover the pharmaceutical detailers’ use in Maine of the prescriber-identifiable data — ■ even though the law appears to have been designed precisely to avoid directly restricting the detailers’ speech to prescribes.
Counsel noted, for example, that “use in Maine is what the statute is directed at and that would be proscribed regardless of whether or not [an out-of-state] transaction before that was subject to the Act.” Counsel also stated that, “[i]f the assumption is that the transaction between IMS or one of the other plaintiffs and the drug companies occur[s] totally outside the State, then what the statute covers is the subsequent use in Maine by the detailer.” That explanation is at odds with my previous understanding of the State’s construction of the statute, which explicitly applies to “a carrier, pharmacy or prescription drug information intermediary” [“PDII”] — not to pharmaceutical companies and their employees. That explanation is also at odds with the district court’s reading of the law. See Rowe, 532 F.Supp.2d at 169 (“The Law does not make illegal a drug company’s use of opt-out prescriber information for marketing purposes.... The Law forbids the PDIIs from selling opt-out data for marketing, but it does not prohibit the pharmaceutical companies from using the data for marketing.”).38
Although the plaintiffs also state in their brief that drug companies fall within the statute’s definition of a PDII, that construction departs from plain language and ordinary usage. It may be, as plaintiffs’ counsel explained at oral argument, that a drug manufacturer could be treated as a PDII when it transacts directly with pharmacies or other sources of prescription data. As a general matter, however, drug companies are not PDIIs, and classifying them as such when they are not acting in that capacity is not a defensible reading of the statute. Thus, my assumption throughout is that the statute does not directly regulate drug manufacturers and their employees, including detailers, unless the drug manufacturer acts as its own PDII.
The confusion over how the statutes operate arises from the States’ attempts to achieve indirectly its ultimate objective— limiting the content of the detailers’ messages. By restricting the dissemination of prescriber-identifiable data rather than the detailers’ messages themselves, the States hoped their laws would be evaluated as restrictions on conduct rather than speech. The First Amendment consequences of regulating the content of speech do not disappear, however, simply because the regulation operates indirectly. See infra. In this instance, the indirection has only *35made the constitutional inquiry more complex.
In particular, the States’ approach magnified the Commerce Clause implications of the legislation because the targeted transfers of preseriber-identifiable data for marketing purposes occur primarily outside of both New Hampshire and Maine. Evidently feeling caught in a constitutional bind, the New Hampshire Attorney General construed her state’s statute to govern only in-state transactions- — -effectively stripping the law of any impact. Although Maine has rejected súch a narrow construction, it is still scrambling to define the reach of its legislation.
In my view, the States should have confronted directly the First Amendment challenges of what they sought to do. Their indirect approach has not avoided First Amendment scrutiny, yet they have generated the Commerce Clause complications that we must address here. Those complications might have been avoided with more straightforward laws addressing the States’ concerns about pharmaceutical detailing.
II. The First Amendment
I recognize that the majority decision in Ayotte is binding precedent for the proposition that the statute at issue here, like the statute in Ayotte, regulates conduct, not speech. See United, States v. Rodriguez, 527 F.3d 221, 224 (1st Cir.2008) (“As a general rule, newly constituted panels in a multi-panel circuit are bound by prior panel decisions closely on point.”). I must re-emphasize, however, my strong disagreement with the Ayotte majority’s conclusion that statutes such as those of New Hampshire and Maine regulate conduct, rather than constitutionally protected speech. The purpose of both laws is to restrict truthful — but, in the States’ view, undesirable — messages communicated by pharmaceutical detailers to prescribing health care professionals. The State of Maine admits that restricting such speech is precisely its objective. Cf. Sorrell, 631 F.Supp.2d at 446 (“Plainly, the whole point of [Vermont’s statute] is to control detailers’ commercial message to prescribers.”). The laws achieve this purpose by regulating the transfer of factual information. It cannot reasonably be argued that these laws, with this ultimate purpose, do not constitute restrictions on speech. See Ayotte, 550 F.3d at 81-82 (Lipez, J., concurring and dissenting) (citing cases); Sorrell, 631 F.Supp.2d at 446 (“The mere fact that [Vermont’s similar provision] regulates protected speech indirectly does not sweep it from the First Amendment’s purview.”); Laurence H. Tribe, Legal Backgrounder, The Fatal First Amendment Flaw in Prescription Restraint Statutes (Wash.Leg. Found., Washington, D.C.), Dec. 11, 2009, available at http://www. wlf.org/publishing/publication_detail.asp?id=2125 (noting that the Supreme Court has “recognized that obstructing access to the informational building blocks of speech is every bit as pernicious an abuse of governmental power over the free flow of information and ideas as is restricting the resulting speech itself’).
In reaching its conclusion in Ayotte that laws such as these are “outside the ambit of the First Amendment,” 550 F.3d at 52, the majority equated transfers of prescriber-identifiable information with the limited categories of speech, such as obscenity and fighting words, that lie “outside the compass of the Free Speech Clause by virtue of longstanding tradition.” Id. at 51-52. In making that comparison, the majority repeatedly discounted the value of the expression that it acknowledged the New Hampshire statute might regulate, describing such “putative speech” as *36“items of nugatory informational value” and “of scant societal value.” Id. at 52.
However, in a recent decision considering a challenge to a law criminalizing depictions of animal cruelty, the Supreme Court firmly rejected the notion that the First Amendment’s guarantee of free speech “extendfs] only to categories of speech that survive an ad hoc balancing of relative social costs and benefits.” Stevens, 130 S.Ct. at 1585. The Court explained that the exclusion of categories of speech from the protection of the First Amendment has occurred only in “special case[s].” Id. at 1586; id. at 1584 (listing the “few limited areas” where “the First Amendment has permitted restrictions upon the content of speech” (quotation marks and citation omitted)). Although observing that other categories of speech may yet be identified as unprotected based on historical practice, the Court stated that its prior decisions “cannot be taken as establishing a freewheeling authority to declare new categories of speech outside the scope of the First Amendment.” Id. at 1586.
These prescriber-information cases involve the right to disseminate truthful information — a classic form of protectible speech activity, even when done for a fee— and the right to use that information in crafting a marketing message. Stevens confirms that such speech may not be excluded from First Amendment protection “on the basis that [it] is not worth it,” 130 S.Ct. at 1585, and labeling speech as conduct does not make that exclusion any more permissible.
Hence, while Ayotte governs the First Amendment analysis in this case, I adhere to my view that what is at stake is protectible speech, not conduct. The relevant First Amendment question is thus whether Maine, like New Hampshire, has adequately justified the limited restraint on commercial speech imposed by its statute. Here, as in Ayotte, I conclude that the State has done so.
Maine asserts three “compelling state interests” in support of section 1711-E(2-A): “to improve public health, to limit annual increases in the cost of health care and to protect the privacy of patients and prescribers” in the State’s health care system. Me.Rev.Stat. Ann. tit. 22, § 1711-E(l-B). Although I agree that these interests are substantial in theory, I doubt that the record supports the State’s contention that the challenged statute in fact advances all of them. I am particularly skeptical of the privacy interest.
The Maine law neither prohibits the practice of pharmaceutical detailing nor prevents the widespread use of any prescriber’s prescribing histories. See Rowe, 532 F.Supp.2d at 170 (“The Attorney General’s expert [prescriber] witnesses acknowledged that insurance companies, governmental agencies, quality assurance committees, utilization reviewers, and others have the right and responsibility to assess their prescribing patterns.”); id. at 173 (“[T]he new Law does not prevent the pharmacies from transferring exactly the same information to the PDIIs, so long as the information is not ultimately used for marketing.”). Detailers may continue to devise marketing strategies based on the prescribing patterns of prescribers who do not choose to bar the marketing use of their information, meaning that the one-on-one meeting with a prescriber who has invoked the law’s protection may include references to the histories of colleagues within the same town or even the same practice. See id. at 171.
Given the wide, permissible dissemination of the prescribing information, and the continued allowance of targeted one-on-one detailing, prescriber privacy does not appear to be meaningfully advanced by this *37statute. Accord Rowe, 532 F.Supp.2d at 173 (“The Law only marginally advances the governmental interest in prescriber privacy.”). I therefore disagree with the majority’s analysis of the State’s “interest in preventing its prescribers from being subjected to unwanted solicitations by detailers in Maine on the basis of their prescribing histories.” The statute does not protect a “right to be let alone”; it merely protects prescribers who consent to interactions with detailers from exposure to one type of message. The prescribers may have particular distaste for sales pitches based on their own prescribing histories, but that discomfort — whether or not properly labeled an issue of “privacy” — seems inadequate to justify a content-based restriction on truthful speech of public concern. See Rowe, 532 F.Supp.2d at 170 (“Prescribers’ prescribing patterns are ... a matter of public concern.”).
In any event, the State’s brief gives short shrift to both the privacy and public health interests, and I find it unnecessary to closely examine the record on those two interests because the State’s substantial interest in reducing health care costs in Maine is sufficient to justify the statute within the commercial speech framework. Cf. Ayotte, 550 F.3d at 88-96; Sorrell, 631 F.Supp.2d at 449-454 (finding that Vermont’s statute advances the State’s interests in both cost containment and protecting public health). Relying on evidence similar to that introduced in Ayotte, the State argues that detailing is “significantly more successful when detailers use prescriber-identifiable data,” and that reduced access to physicians’ prescribing histories will reduce the likelihood that prescribers in Maine will prescribe “unnecessary and more expensive brand-name drugs.” I will not rehearse in detail the nature of the evidence presented on this issue at the Maine legislative hearings or before the district court. It suffices to say that the record “establishes a plausible cause-and-effect relationship between targeted detailing and higher drug prices,” Ayotte, 550 F.3d at 93, and that “the Attorney General has [thus] sufficiently demonstrated that the State’s interest in cost-containment would be furthered ‘to a material degree’ by the limitation on speech it seeks to achieve through [section 1711-E(2-A) ],” id. at 94.
To satisfy the First Amendment, the statute also must meet the narrow tailoring prong of the Central Hudson inquiry. See Central Hudson Gas & Elec. Corp. v. Pub. Serv. Comm’n, 447 U.S. 557, 566, 100 S.Ct. 2343, 65 L.Ed.2d 341 (1980). Without the benefit of our decision in Ayotte, the district court concluded that the Maine law “substantially fails” the narrow tailoring requirement. Rowe, 532 F.Supp.2d at 176. That judgment is wrong largely for the same reasons that it was wrong in Ayotte.
In concluding that the law is more extensive than necessary to serve the State’s interest in decreasing the influence of drug company representatives, the district court emphasized that the State did not address the concern that detailers “inappropriately influence] Maine prescribers by showering them with gifts in implicit exchange for prescriptions.” Id. It also pointed out that prescribers are “[t]rained as professionals” “to perform a sophisticated and critical public health function.” Id. at 177. It stated that these trained professionals “have access to a broad range of sources to evaluate whether to prescribe a drug for a particular patient.” Id. Therefore, the law unnecessarily protects them “from being influenced by their own practice patterns.” Id. Specifically on the cost issue, the district court observed that “some branded drugs end up being more cost effective to the system as a whole than their generic or branded counterparts.” Id. at 178. In *38that sense, the court stated, the Maine law fails to “discriminate between beneficial detailing and harmful detailing.” Id. (quotation marks and citation omitted). The court thus concluded that “ban[ning] truthful information about opt-out prescribers’ prescription patterns is to overreach and restrict more speech than is necessary to address the problem of harmful detailing.” Id.
The district court’s narrow tailoring assessment does not adequately take into account the premise from which it must proceed, i.e., that the State has shown that restricting the use of prescriber-identifiable data advances at least one of its asserted interests' — controlling the spiraling cost of prescription drugs. The court seems to assume that the alternatives it describes will be just as effective in advancing that goal.
As I have explained, the State’s evidence in both Ayotte and here supports the view that, despite the expertise of medical professionals, detailers are able to influence prescribing decisions. I also explained in Ayotte why the State could properly conclude that alternative methods for achieving its cost-containment objective that would not burden speech, including restricting courtesy samples and other gifts, were not equivalent. As I noted there, “[t]he samples and gifts are merely a preparatory step in the marketing process; while they may increase the prescribers’ susceptibility to the sales pitch, the State reasonably concluded that it is the sales pitch itself that has the most troubling effect on the prescribers’ drug choice — and is most urgently in need of regulation.” 550 F.3d at 99.39
The fact that detailing at times has beneficial effects does not undermine the State’s conclusion that, on balance, its harms outweigh its benefits — particularly where the State reasonably could find that the benefits of the messages about prescription drugs that are disseminated by detailers are “largely achievable in other ways.” 550 F.3d at 95-9640; see also Rowe, 532 F.Supp.2d at 177. Notably, the State’s restriction on speech is significantly more restrained than other marketing or advertising bans that have been considered by the Supreme Court. See Ayotte, 550 F.3d at 97 (citing cases involving more comprehensive restrictions). As I described in Ayotte, the private setting of the targeted messages also is relevant to the narrow tailoring inquiry:
This case differs from those in which the Court has rejected advertising bans that *39restrict the exchange of ideas in the “commercial marketplace.” The [Act] neither “protects” the public from information about drugs nor prevents truthful advocacy by pharmaceutical representatives. Instead, it prevents sales representatives from crafting personal marketing messages on the basis of data that credible evidence indicates has been used to unduly influence prescribing choices. The Supreme Court on multiple occasions has reviewed regulation of such direct solicitations, upholding restrictions where the context raised concerns about the impact of the marketing on the recipient.
550 F.3d at 100.
Indeed, the narrow tailoring element of the Central Hudson test is arguably more easily satisfied here than in Ayotte because the statute bars the marketing use of prescribing histories only for prescribers who affirmatively choose not to have their data used for marketing purposes — narrowing the impact on protected speech. Although the State’s cost-containment objective would have modest success, at best, if few Maine prescribers choose to restrict the use of their prescribing data, the restriction on protected speech also would be modest in that situation. I see no constitutional barrier to the State’s judgment that restricting the use of prescriber-identifiable data in the detailing messages of only some of its prescribers would be beneficial.41
In sum, the considerations I addressed in Ayotte to evaluate “ ‘whether the extent of the restriction on protected speech is in reasonable proportion to the interest served,’ ” 550 F.3d at 96 (quoting Edenfield v. Fane, 507 U.S. 761, 767, 113 S.Ct. 1792, 123 L.Ed.2d 543 (1993)), apply here as well: “[t]he inadequacy of alternatives to satisfy the State’s interests, the context of private communications, and the limited impact on the message sought to be disseminated.” 550 F.3d at 98. My review of these factors leads me to the same conclusion: the State “has established a ‘reasonable fit’ between its abridgement of speech and its ... goal.” Id. at 98 (quotation marks and citation omitted); see also Sorrell, 631 F.Supp.2d at 455 (finding the Vermont statute to be “in reasonable proportion to the State’s interests”).
Hence, like New Hampshire, Maine has met its burden to justify the limited restraint on commercial speech imposed by section 1711-E(2-A).
III. The Commerce Clause
This case confirms the view I expressed in Ayotte that the plaintiffs’ Commerce Clause challenge raised a serious issue that should not have been addressed in that case on the basis of the limited record and the parties’ cursory briefing. Maine distances itself from the nonsensical construction of the New Hampshire statute that was advanced by the New Hampshire Attorney General and accepted by the Ayotte majority,42 admitting that its statute *40inevitably reaches out of state to regulate sales of data about prescriptions written in Maine. Indeed, the activity restricted by the Maine statute, logically construed, occurs almost entirely beyond the State’s borders.43
A. The Activities Regulated by the Statute
Understanding the sequence of events implicated by section 1711-E(2-A) is crucial to understanding the statute’s legal status. To begin with the end, the statute is designed to prevent pharmaceutical detailers working in Maine from using information about the prescribing habits of Maine prescribers to present targeted, and therefore more persuasive, sales pitches to those prescribers. The statute does not, however, regulate the detailers’ interactions with the prescribers. Instead, the State seeks to achieve its objective indirectly by, in effect, placing a red flag on information about prescriptions written by Maine prescribers who opt into the statute’s protection. The red-flagged information may not be used, sold or transferred “for any marketing purpose” by pharmacies, insurers and other entities that acquire it in the course of their business.44
In practical effect, that prohibition rarely limits any commercial transactions in Maine. This is so because local Maine pharmacies routinely transfer their prescription information electronically to their out-of-state headquarters.45 Although the red flag is attached to the information when those transfers are made, the statutory prohibition does not affect this first movement of the data because it is not “for any marketing purpose.” Most prescriber-identifiable data leaves the State in this permissible manner. The data is next transferred from the out-of-state pharmacy headquarters to the data mining companies' — the plaintiffs in this case-who also are located outside of Maine.46 The red flag imposes a significant restriction on those out-of-state transactions. Although data miners use prescription information for other reasons, including to generate reports for government and other nonprofit recipients, the most lucrative aspect of their business is to aggregate the information into reports that can be sold to pharmaceutical companies for use in marketing.47
Hence, the pharmacies and data miners, although not themselves using the preseri*41ber-identifiable data to market drugs, presumably must impose a contractual obligation on their customers not to use the information for that purpose in order to fulfill their obligations under section 1711— E(2-A). See Rowe, 532 F.Supp.2d at 169 n. 18 (“[T]he PDIIs are assigned the responsibility to limit the pharmaceutical companies’ use of the opt-out prescriber data.”). How the State would enforce the statute if a pharmaceutical manufacturer does not abide by such a contract with a data miner is unclear. Perhaps the data miners would be deemed liable for failing to enforce the obligation unless they took action against the offending drug company; such action might include a refusal to continue selling the information to the company.48
Whatever the specific mechanism for enforcement of the statute’s prohibition, the statute’s objective is to prevent the use of any prescriber-identifiable data obtained by the drug companies in sales pitches by the detailers in Maine who are the statute’s real target.49 As my description of the process reveals, however, achieving that objective involves raising the red flag in transactions that almost all occur beyond Maine’s borders. Nearly all of the transfers between the information possessors' — the pharmacies and data miners— and the information recipients — the data miners and pharmaceutical companies— are made out of state. So too are any contractual promises by the recipients to abide by the statute’s limitation.
The plaintiffs complain that this significant extraterritorial effect is impermissible under the dormant Commerce Clause. The State, however, maintains that the statute has only a “spillover effect” beyond its borders, and it argues that the law applies only to “entities either located in Maine or having nexus with Maine,” i.e., those sufficiently connected to the State to meet the requirements for personal jurisdiction. The State asserts that it is “irrelevant” that the main computers of the large retail pharmacy chains are located outside Maine because Maine is the source of the restricted information, and the electronic prescription data is initially entered into in-state computers. The State further emphasizes that the prescriptions are written by prescribers licensed by Maine and filled almost exclusively by State-licensed pharmacies, giving Maine a substantial interest in governing the dissemination and use of the prescription data.
The difficulty of evaluating the parties’ competing depictions of section 1711-E(2-A) begins with the choice of an appropriate framework for analysis.
B. Identifying the Correct Analytical Approach
The Supreme Court has articulated various “protocols] for dormant Commerce *42Clause analysis,” Dep’t of Revenue of Ky. v. Davis, 553 U.S. 328, 338, 128 S.Ct. 1801, 170 L.Ed.2d 685 (2008), none of which seems fully apt here. This is plainly not an instance of discriminatory purpose or treatment in which the statute should be deemed per se invalid because it favors instate over out-of-state interests. See, e.g., Alliance of Auto. Mfrs. v. Gwadoosky, 430 F.3d 30, 35-36 (1st Cir.2005) (noting that the “core purpose” of the dormant Commerce Clause is “to prevent states and their political subdivisions from promulgating protectionist policies” (quotation marks and citation omitted)). The law imposes the same burden on every competitor, and out-of-state entities would gain no advantage by relocating to Maine.50
Plaintiffs, unsurprisingly, have relied primarily on the extraterritoriality doctrine, and the proposition that a statute may be deemed per se invalid if it “directly controls commerce occurring wholly outside the boundaries of a State.” Healy v. Beer Inst., Inc. 491 U.S. 324, 336, 109 S.Ct. 2491, 105 L.Ed.2d 275 (1989); see also Wine & Spirits Retailers, Inc. v. Rhode Island [“Wine & Spirits II”], 481 F.3d 1, 15 (1st Cir.2007); Pharm. Research & Mfrs. of Am. v. Concannon [“PhRMA ”], 249 F.3d 66, 79-80 (1st Cir.2001), aff'd sub nom. Pharm. Research & Mfrs. of Am. v. Walsh, 538 U.S. 644, 123 S.Ct. 1855, 155 L.Ed.2d 889 (2003). Such laws may subject activities to more than one state’s regulations, leading to the possibility of conflicting obligations. See, e.g., Healy, 491 U.S. at 336-37, 109 S.Ct. 2491; CTS Corp. v. Dynamics Corp. of Am., 481 U.S. 69, 88-89, 107 S.Ct. 1637, 95 L.Ed.2d 67 (1987); Peter C. Felmly, Comment, Beyond the Reach of States: The Dormant Commerce Clause, ExtratemtoHal State Regulation, and the Concerns of Federalism, 55 Me. L.Rev. 467, 509 (2003) (observing that the extraterritoriality “principle ensures that a state will not overstep its bounds and unreasonably trample upon the authority of another sovereign”). Plaintiffs also invoke the so-called Pike balancing test, which is applied to laws that regulate evenhandedly and have only “incidental” effects on interstate commerce. See Pike v. Bruce Church, Inc., 397 U.S. 137, 142, 90 S.Ct. 844, 25 L.Ed.2d 174 (1970);51 see also United Haulers Ass’n, Inc. v. Oneida-Herkimer Solid Waste Mgmt. Auth., 550 U.S. 330, 346, 127 S.Ct. 1786, 167 L.Ed.2d 655 (2007).52
Neither of these latter alternatives is a good fit for the present circumstances. The per se extraterritoriality analysis may appear literally applicable, given that the statute’s red flag has a direct impact almost exclusively on out-of-state commerce. Yet, as I observed in Ayotte, “whether extraterritoriality is impermissible in ev*43ery instance, or whether it transgresses the dormant Commerce Clause only when the challenged statute is discriminatory or protectionist in nature, appears to be [a] relevant consideration.” 550 F.3d at 105 (citing Felmly, supra, at 491). The Maine law does not by its terms impose restraints on non-domestic businesses, and the imbalance between in-state and out-of-state effect is a matter of happenstance not design. The statute does not seek to achieve conformity between in-state and out-of-state commerce.53 Additionally, there is no risk of conflict with other states’ regimes. No other State has a stake in the use of prescriber-identifiable data in Maine or any obvious interest in the use of Maine prescribe!’ information in their own locales.
Indeed, it is arguable that, despite the statute’s impact on commercial transactions that occur almost entirely out of state, the commerce it controls is not “wholly outside [Maine’s] boundaries.” Healy, 491 U.S. at 336, 109 S.Ct. 2491. The subject matter of the law is data that both originates in Maine and is intended for marketing use in Maine. Maine’s aim is to regulate on a matter of public welfare only within Maine. Cf. Midwest Title Loans, Inc. v. Mills, 593 F.3d 660, 667-68 (7th Cir.2010) (invalidating Indiana statute that sought to protect Indiana residents from predatory lending practices by businesses located in other states). On the other hand, it is difficult to characterize the statute’s effect on out-of-state commerce as “incidental” when its prohibition in fact has its primary impact outside the State. See, e.g., Healy, 491 U.S. at 336, 109 S.Ct. 2491 (“The critical inquiry is whether the practical effect of the regulation is to control conduct beyond the boundaries of the State.”).
The various labels ordinarily are invoked because they are associated with different levels of scrutiny. We have observed that a statute that regulates evenhandedly “engenders a lower level of scrutiny,” Wine and Spirits II, 481 F.3d at 11 (quotation marks and citation omitted), while “[a] statute is per se invalid if it regulates commerce wholly outside the state’s borders,” id. at 15. Identifying the appropriate label should not distract us, however, or bog us down at the threshold of analysis. Despite the different protocols for dormant Commerce Clause inquiry, the Supreme Court has observed that “there is no clear line separating” the various types of state regulation and that the same “critical consideration” applies to each category: “the overall effect of the statute on both local and interstate activity.” Brown-Forman Distillers Corp. v. New York State Liquor Auth., 476 U.S. 573, 579, 106 S.Ct. 2080, 90 L.Ed.2d 552 (1986) (referring to regulations that are “virtually per se invalid under the Commerce Clause, and the category subject to the Pike v. *44Bruce Church balancing approach”); see also Healy, 491 U.S. at 337 n. 14, 109 S.Ct. 2491 (noting the same “critical consideration” in determining “whether the extraterritorial reach of a statute violates the Commerce Clause”); Am. Booksellers Found v. Dean, 342 F.3d 96, 102 (2d Cir.2003).
This dual concern is an inevitable byproduct of our system of federalism. The Court has often remarked in its dormant Commerce Clause cases that States “retain authority under their general police powers to regulate matters of legitimate local concern, even though interstate commerce may be affected.” Maine v. Taylor, 477 U.S. 131, 138, 106 S.Ct. 2440, 91 L.Ed.2d 110 (1986) (quotation marks and citation omitted); see also, e.g., Davis, 553 U.S. at 338, 128 S.Ct. 1801; cf. Garcia v. San Antonio Metro. Transit Auth., 469 U.S. 528, 546, 105 S.Ct. 1005, 83 L.Ed.2d 1016 (1985). Hence, in reviewing a statute challenged under the dormant Commerce Clause, we are always guided by “the Constitution’s special concern both with the maintenance of a national economic union unfettered by state-imposed limitations on interstate commerce and with the autonomy of the individual States within their respective spheres.” Healy, 491 U.S. at 335-36, 109 S.Ct. 2491 (footnote omitted).
Indeed, even the “rigorous form of review” applicable to discriminatory legislation allows exemption for a statute that “furthers a legitimate local objective that cannot be served by reasonable non-discriminatory means.” Wine and Spirits II, 481 F.3d at 11. Local needs also must qualify the “near-fatal rule of per se invalidity” for statutes that regulate extraterritorially. See Felmly, supra, at 492; id. at 488 (observing that “[o]ne may infer” from language in CTS Corp., 481 U.S. at 93, 107 S.Ct. 1637, that “where a state has a significant interest in regulating a particular aspect of interstate commerce, it may do so, regardless of the extraterritorial effect of the legislation, if the regulation also affects a substantial number of in-state residents”).
I thus see the most relevant and appropriate question as simply whether Maine’s interests are sufficiently weighty to justify any burdens its law imposes on interstate commerce. Whatever the label and however we describe the level of scrutiny, the outcome here is the same.
C. Assessing the Local Interest and the Burden on Interstate Commerce
As discussed in Section II above, I agree that the State has a substantial interest in reducing the cost of prescription drugs for its residents and that the State could reasonably conclude that section 1711-E(2-A) advances that interest by regulating the dissemination of information revealing the prescribing histories of Maine’s licensed health care providers. Cf. Ayotte, 550 F.3d at 94-95. The statute’s importance to the State is no different in the context of a Commerce Clause inquiry than in the First Amendment setting.
The other side of the balance is not the same, however. The conclusion that the statute is “narrowly tailored” under the Central Hudson test for commercial speech, see 447 U.S. at 566, 100 S.Ct. 2343, does not tell us whether the provision impermissibly burdens interstate commerce. As I have described, the statute does in fact regulate specific activities that occur mostly out of state. The impact on the plaintiffs is not merely “spillover” from a prohibition directed at others; they are among the categories of entities — PDIIs— affected directly by the statute.
Moreover, the statute’s impact on PDIIs is potentially enormous. Sales of prescriber-identifiable data are the bread-and-butter of the medical data mining business, *45producing $1.75 billion in revenue for plaintiff IMS Health alone in 2005. Although only three states have thus far enacted laws designed to limit detailers’ access to prescribers’ identifying information, they are at the front of a wave of similar legislation. See Rowe, 532 F.Supp.2d at 180 n. 41 (noting testimony that seventeen to twenty other states were considering similar laws); Heesters, supra, at 791 (stating that “numerous other states have [bills] that similarly restrict the sale of prescription drug data that are currently pending in legislative committees”).
Hence, a conclusion that section 1711— E(2-A) comports with the dormant Commerce Clause could eventually lead to elimination of any market for preseriberidentifiable data, which the plaintiffs have argued would jeopardize the viability of their businesses. See Ayotte, 550 F.3d at 95 n. 66 (“Plaintiffs theorize that the pharmaceutical companies would be unwilling to pay substantial sums for information they cannot use in marketing, eliminating the data miners’ biggest customers— thereby cutting off the commercial funding that subsidizes the research and other non-commercial uses of the data.”).54 Plaintiff IMS asserts that it will cost hundreds of thousands of dollars for it to adjust its systems to comply with the statute’s restrictions; plaintiff Source Healthcare estimated that it would spend 10,000 employee hours to comply with Maine’s and Vermont’s laws.
The “possible effects on the profits of the individual manufacturers” is not, however, the concern of the dormant Commerce Clause. PhRMA 249 F.3d at 84. Our court previously has observed that “the Commerce Clause ... ‘protects the interstate market, not particular interstate firms, from prohibitive or burdensome regulations.’ ” Pharm. Care Mgmt. Ass’n v. Rowe, 429 F.3d 294, 313 (1st Cir.2005) (quoting Exxon Corp. v. Gov. of Md., 437 U.S. 117, 127-28, 98 S.Ct. 2207, 57 L.Ed.2d 91 (1978)); see also PhRMA 249 F.3d at 84 (“[T]he fact that a law may have devastating economic consequences on a particular interstate firm is not sufficient to rise to a Commerce Clause burden.” (quotation marks and citations omitted)). Even if the statute meant the demise of the data-mining industry as a whole — an outcome I doubt, see infra note 22 — any ill-effects from that result would “relate[] to the wisdom of the statute, not to its burden on commerce.” Exxon Corp., 437 U.S. at 128, 98 S.Ct. 2207. The point is perhaps more easily understood in a different context. If, for example, every state decided to ban the use of firecrackers because of the risk of injury, the dormant Commerce Clause would not trump the legislative safety concerns and insulate the fireworks industry from extinction.
Neither national uniformity nor any of the other traditional concerns underlying the dormant Commerce Clause are implicated here. The law does not “erect barriers against interstate trade,” Lewis v. BT. Inv. Managers, Inc., 447 U.S. 27, 35, 100 S.Ct. 2009, 64 L.Ed.2d 702 (1980), and its target is not “interstate commerce” as such. Rather, the transactions governed by the statute are restricted only because they are subsidiary steps in the regulation of in-state activity.55 Indeed, the law’s *46effect on individual businesses would be no different if every PDII were based in Maine. Nor does Maine’s decision to restrict the use of certain prescriber-identifiable data make similar legislation more or less appropriate or necessary in other states. There is nothing in Maine’s statute that affects other states’ choices about whether, or how, to regulate prescriberidentifiable data within their own borders. As the Supreme Court observed in Exxon Corp., “[t]he evil that appellants perceive in this litigation is not that the several States will enact differing regulations, but rather that they will all conclude that [similar] provisions are warranted.” 437 U.S. at 128, 98 S.Ct. 2207. However, “[i]n the absence of a relevant congressional declaration of policy, or a showing of a specific discrimination against, or burdening of, interstate commerce, we cannot conclude that the States are without power to regulate in this area.” Id. at 128-29, 98 S.Ct. 2207.
Nor do I see a way in which Maine could have promoted its interest “ ‘with a lesser impact on interstate activities,’ ” Minnesota v. Clover Leaf Creamery Co., 449 U.S. 456, 471, 101 S.Ct. 715, 66 L.Ed.2d 659 (1981) (quoting Pike, 397 U.S. at 142, 90 S.Ct. 844) — a factor that is considered in Pike balancing. See, e.g., U & I Sanitation v. Columbus, 205 F.3d 1063, 1070-71 (8th Cir.2000). If Maine had regulated only in-state activity — directly barring detailers working in Maine from using the opted-out prescribers’ data in their sales pitches — the impact on data miners would be the same. In such a regime, the out-of-state data miners would not be prohibited from selling the prescriber-identifiable data for marketing purposes, but the pharmaceutical companies would have no reason to buy it.56
In sum, I conclude that section 1711-E(2-A) survives dormant Commerce Clause scrutiny even though in practical effect it regulates activity that occurs primarily beyond Maine’s borders. The burden on interstate commerce (the reduction in the value of a particular type of business) is not the kind of burden that raises constitutional concerns. To the extent that burden is relevant to the Commerce Clause analysis, it is easily outweighed by the State’s substantial interest in bringing the cost of prescription drugs — and health care expenses in general' — under control. Cf. Pharm. Care Mgmt. Ass’n, 429 F.3d at 312 (describing a law aimed at “reducing] the costs of, and increasing] the public’s access to, prescription drugs” as “designed to deal with ‘one of the serious problems of our time’ ”).
*47I therefore agree that the judgment of the district court should be reversed.
IV. The Focus of Future Litigation
This case has allowed us to put to rest the Commerce Clause challenge that was not properly teed up in Ayotte. In addition, in the period between our reviews of New Hampshire’s and Maine’s similar statutes, Stevens has reinforced my view that laws regulating the messages of pharmaceutical detailers restrict protectible speech, not conduct. Thus, as more of these cases evolve across the country, the legal argument and factual development should be framed by the Supreme Court’s commercial speech doctrine under the First Amendment.
That doctrine is the subject of ongoing debate among commentators and in the courts, including within the Supreme Court. Much of the ferment focuses on the narrow tailoring prong of the Central Hudson inquiry and how close the fit must be in any commercial speech case between the State’s interest and the challenged restriction on speech. See Greater New Orleans Broad. Ass’n, Inc. v. United States, 527 U.S. 173, 184, 119 S.Ct. 1923, 144 L.Ed.2d 161 (1999) (recognizing the advocacy among judges, scholars and others for “a more straightforward and stringent test for assessing the validity of government restrictions on commercial speech”); see also Thompson v. W. States Med. Ctr., 535 U.S. 357, 388, 122 S.Ct. 1497, 152 L.Ed.2d 563 (2002) (Breyer, J., dissenting) (chastising the majority for applying the commercial speech doctrine “too strictly” in finding that a statute prohibiting the advertising of compounded drugs was not narrowly tailored); Ayotte, 550 F.3d at 96-97 (discussing “the debate on Central Hudson’s continuing viability”); Elizabeth Spring, Note, Sales Versus Safety: The Loss of Balance in the Commercial Speech Standard in Thompson v. Western States Medical Center, 37 U.C. Davis L.Rev. 1389, 1404 (2004) (“[T]he Court is now applying the Central Hudson test in a manner approaching strict scrutiny review.”).
In addition, there is a claim by some that these particular laws should not be assessed as regulations of commercial speech, with the lesser scrutiny that attends such measures, but rather as content-based regulations of truthful speech “on matters of profound public importance.” Tribe, supra; see also Rowe, 532 F.Supp.2d at 167 n. 14 (describing as a “thorny question” whether Maine’s content-based regulation should be given intermediate or strict scrutiny and raising the possibility that “the speech here is not purely commercial speech and is subject to strict scrutiny” because it is “a matter of public concern”); cf. Tribe, supra (“Even if the prescription restraint laws were subject to the more forgiving standard applicable to regulations of purely commercial speech, however, they would still be unconstitutional because they violate the core principle that the government may not restrict even commercial communication merely to block the dissemination of truth.”). Although in Ayotte I found no merit in the argument that New Hampshire’s statute should be analyzed as a content-based restriction on speech subject to strict scrutiny, see Ayotte, 550 F.3d at 83 n. 47; accord Sorrell, 631 F.Supp.2d at 447-48,57 the contrary view has worthy *48proponents and undoubtedly deserves close consideration.
Yet another source of difficulty is the quality of the record a state legislature must amass to prove that a statute advances its interest and extends no more broadly than necessary to achieve its objectives. I concluded in Ayotte that the district court had held the Attorney General to an overly demanding standard of proof. Here, too, the court underestimated the strength of the State’s showing. As I explained in Ayotte, a state legislature’s investigation cannot reasonably be expected to match the exhaustive investigation Congress conducts in connection with complex federal legislation. See 550 F.3d at 92-93 (referring to the “ ‘tens of thousands of pages’ of materials” acquired during three years of Congressional hearings on provisions of the Cable Television Consumer Protection and Competition Act of 1992).
Although the extent of the required proof may differ, the question in both federal and state contexts is the same: “whether the government is able to support its restriction on speech by ‘ad-ducting] either empirical support or at least sound reasoning on behalf of its measure[ ].’ ” Id. at 93 (quoting Turner Broad. Sys., Inc. v. FCC, 512 U.S. 622, 666, 114 S.Ct. 2445, 129 L.Ed.2d 497 (1994)). A further complexity, however, is whether “the general principle of legislative deference” should operate the same way in both settings, despite differences in the scope of the underlying record. Id. In Turner Broadcasting, the Supreme Court observed that Congress’s findings were entitled to “deference in part because the institution is far better equipped than the judiciary to amass and evaluate the vast amounts of data bearing upon legislative questions.” Turner Broad. Sys., Inc. v. FCC, 520 U.S. 180, 195, 117 S.Ct. 1174, 137 L.Ed.2d 369 (1997) (quotation marks and citation omitted).
The district court in this case puzzled over the appropriate level of deference for the legislature’s findings, noting the subtle “distinction between judicial deference and judicial respect to a legislature in a First Amendment case.” 532 F.Supp.2d at 178. It noted the Ayotte trial court’s conclusion that the legislature’s “predictive judgments” were “entitled to respect, but not deference, because there was nothing in the record ‘to support a conclusion that the legislature had established expertise in the regulation of prescriber-identifiable data.’ ” Id. (quoting IMS Health Inc. v. Ayotte, 490 F.Supp.2d 163, 177 n. 12 (D.N.H. 2007)).58 Yet the court also cited the Supreme Court’s statement in Turner Broadcasting that “the ‘obligation to exercise independent judgment when First Amendment rights are implicated is not a license to reweigh the evidence de novo, or to replace [legislative] factual predictions with our own.’ ” Id. at 178-79, 117 S.Ct. 1174. Indeed, the Supreme Court has “permitted litigants to justify speech restrictions by reference to studies and anecdotes pertaining to different locales altogether, or even, in a case applying strict scrutiny, to justify restrictions based solely on history, consensus, and ‘simple common sense.’ ” Florida Bar v. Went For It, Inc., 515 U.S. 618, 628, 115 S.Ct. 2371, 132 L.Ed.2d 541 (1995) (citations omitted).
The legislative records in New Hampshire and Maine were necessarily limited. Given the novelty of their statutes, neither State could offer “empirical data showing the extent of the influence of prescriber*49specific information on physicians’ decision-making” or proving the cost-cutting impact of their provisions. 550 F.3d at 93. Both States, however, adduced evidence of the impact of detailing generally and presented anecdotal evidence “strongly indicating that sales pitches based on specific prescribing patterns have a particularly persuasive impact on drug choice.” Id. at 94; Rowe, 532 F.Supp.2d at 172. New Hampshire offered expert evidence in defense of its view that alternative strategies, less burdensome on speech, would not suffice. Ayotte, 550 F.3d at 100. At this point in time, such evidence was sufficient in each case to “establish[] a factual basis justifying the initiative.” Id. at 94. Equivalent evidence may not be enough to support the adoption of similar legislation in other states, however, if more extensive quantifiable data becomes available. Cf. Ayotte, 550 F.3d at 93-94 (“[I]t will be important going forward for the State to try to measure the cost-containment effect of its initiative, and it is possible that this ongoing assessment will indicate that the measure is not as effective as the State had hoped.”).
Without a doubt, the States must have flexibility to experiment with measures that will help them address the serious problem of spiraling drug costs. At the same time, the restriction of speech based on its content is a serious constitutional matter. The tension between those principles in laws such as those enacted in New Hampshire, Maine and Vermont presents a challenge to the Supreme Court’s commercial speech jurisprudence that warrants the Court’s attention and guidance.

. The decision in Sorrell has been appealed to the Second Circuit, and oral argument in the case (No. 09-1913) was heard on October 13, 2009.

. Each statute operates slightly differently. The New Hampshire law imposes an outright prohibition on the sale or use of prescriberidentifiable data for marketing purposes. N.H.Rev.Stat. Ann. §§ 318:47-f, 318:47-g, 318-B:12(IV) (2006). Maine's statute imposes such a prohibition only for prescribers who choose to prevent their prescribing information from being used to market prescription drugs to them — the so-called "opt-out” approach. Me.Rev.Stat. Ann. tit. 22, § 1711-E(2-A). Vermont's law has an "opt-in” feature, prohibiting certain entities from selling or using prescriber-identifiable data for marketing or promoting prescription drugs unless the prescriber consents. Vt. Stat. Ann. tit. 18, § 4631.

. The Vermont statute limits the exchange of prescriber-identifiable information among the same entities as the New Hampshire and Maine provisions, but it also bars pharmaceutical manufacturers and marketers from using the information for marketing or promoting a prescription drug unless the prescriber consents. See Vt. Stat. Ann. tit. 18, § 4631(d).

. The majority in this case makes the same assumption: "Section 1711-E(2-A) does not explicitly limit detailers’ use of prescriberidentifying data, but the earlier stages of regulation are meant to prevent this information from getting to detailers for use in marketing.”

. Moreover, Dr. Jerry Avorn, who also served as an expert in this case, testified in Ayotte that other approaches had been tried “nationally in terms of trying to restrict the freebies, trying to provide doctors with other means of learning, requiring that doctors take continuing ed courses,” but that these strategies did not eliminate “this massive distortion of what doctors are prescribing and what the State, and its citizens, are paying for drugs because of the very heavily and very effective promotional strategies that are going on out there.” 500 F.3d at 99.

. I described in Ayotte some of the ways in which such messages would continue to reach prescribers:
News reports, for example, would highlight truly groundbreaking new therapies in a timely way and, indeed, pharmaceutical detailers with knowledge of physicians’ medical specialties presumably would not need access to prescribing histories to effectively promote such innovations. Early adopters could be expected to respond quickly with an interest in trying the new medications-effectively identifying themselves to the sales representatives. In addition, ... the statute does not bar drug companies from alerting prescribers to newly discovered problems with their medications.
550 F.3d at 95 (footnotes omitted). Doctors also testified that they learned about new drugs from medical literature, conferences, and colleagues. Id. at 95 n. 64

. The district court noted that, because the Maine statute gives prescribers the option to allow use of their information, the pharmaceutical companies might provide incentives to prescribers in an attempt to persuade them not to opt out — creating an even more troubling relationship between prescribers and drug manufacturers. Rowe, 532 F.Supp.2d at 174 n. 31; id. at 176 n. 35. In my view, such a scenario is too speculative to factor into the analysis.

. The New Hampshire Attorney General urged the court to read the act to " 'relate only to activity that takes place domestically,' " and the panel majority adopted that view despite recognizing that, so construed, the law “may not accomplish very much.” Ayotte, 550 F.3d at 63, 64.

. Although the Attorney General at oral argument attempted to avoid committing to any specific extraterritorial reach for the statute, I agree with the majority that "[t]he text of the statute by its terms shows section 1711-E(2-A) was intended to apply to plaintiffs’ out of state use or sale of opted-in Maine prescribers’ identifying data.”

. The statute also prohibits licensing or exchanging the information for value. For the sake of simplicity, I will refer primarily to the prohibitions on the sale or transfer of the data.

. The record indicates that, other than the data from one small supplier in Maine, the prescriber-identifiable information obtained by the plaintiffs is transferred in the ordinary course of business from retail stores located in Maine to the pharmacy chains’ out-of-state headquarters.

. An IMS senior vice president testified that the company contracts with Rite Aid at its headquarters in Pennsylvania and with CVS at its headquarters in Rhode Island. IMS is based in Plymouth Meeting, Pennsylvania.

. Drug companies also have non-marketing uses for prescriber-identified data, including determining the need for new drugs and implementing prescription recall programs. Ayotte, 550 F.3d at 74 n. 29. Still, at oral argument, plaintiffs' counsel stated that "[n]inetyfive percent of what we do in selling to a pharmaceutical manufacturer is so that it can use the information for marketing and detail.”

. The district court described the "burden on pharmacies and PDIIs to police their customers” as follows:
They can still sell the opt-out information, but they cannot do so if their customers, the pharmaceutical companies, are going to use the information for a purpose that the Law prohibits. If the PDIIs successfully police their contracts with the pharmaceutical companies, as the Law contemplates, the pharmaceutical companies will not be able to include opt-out prescriber information in marketing their products. If they do not, then they, not the pharmaceutical companies, are subject to sanction.
532 F.Supp.2d at 169.

. The State argues that the record contains no evidence about the transactions between the plaintiff data miners and the drug manufacturers. IMS, however, asserts in its brief that none of its subscribers are located in Maine, and it cites the testimony of Hossam Sadek, a senior vice president of the company, who stated that he knew of no IMS customers in the State.

.Price controls that favor in-state businesses, assessments that function as protective tariffs, and regulations that cap in-state prices for goods produced out of state are classic examples of measures that run afoul of this aspect of the dormant Commerce Clause. See, e.g., Pharm. Research & Mfrs. of Am. v. Walsh, 538 U.S. 644, 669-70, 123 S.Ct. 1855, 155 L.Ed.2d 889 (2003); Or. Waste Sys., Inc. v. Dep’t of Envtl. Quality, 511 U.S. 93, 99, 114 S.Ct. 1345, 128 L.Ed.2d 13 (1994); Healy v. Beer Inst., Inc., 491 U.S. 324, 336, 109 S.Ct. 2491, 105 L.Ed.2d 275 (1989).

. The Court in Pike held that, when a statute regulates evenhandedly to effectuate a legitimate local purpose, and has only incidental effects on interstate commerce, "it will be upheld unless the burden imposed on such commerce is clearly excessive in relation to the putative local benefits." 397 U.S. at 142, 90 S.Ct. 844.

. I disagree with the majority’s assertion that the plaintiffs have waived any Pike balancing argument. Given the similarity of the inquiries under the different strands of the dormant Commerce Clause, I see no reason to disregard the argument here.

. The pursuit of such consistency is a feature of the most prominent Supreme Court extraterritoriality precedents. In Healy, 491 U.S. at 335, 109 S.Ct. 2491, the challenged Connecticut statute expressly required out-of-state shippers to affirm that their Connecticut prices were no higher than the prices being charged in bordering states, and the New York statute at issue in Brown-Forman Distillers Corp. v. New York State Liquor Authority, 476 U.S. 573, 579, 106 S.Ct. 2080, 90 L.Ed.2d 552 (1986), required liquor producers and distillers doing business in the State to affirm comparable in-state and out-of-state pricing. In Baldwin v. G.A.F. Seelig, Inc., 294 U.S. 511, 55 S.Ct. 497, 79 L.Ed. 1032 (1935), the Court struck down the New York Milk Control Act, which prescribed minimum prices for milk that had the effect of setting out-of-state milk prices. Id. at 524, 55 S.Ct. 497. In line with those cases, the Seventh Circuit recently struck down an Indiana law that subjected out-of-state loans entered into by Indiana residents to the requirements of Indiana’s consumer law if the out-of-state creditor had advertised or solicited sales in Indiana. Midwest Title Loans, Inc. v. Mills, 593 F.3d 660, 662, 667-68 (7th Cir.2010).

. The fact that only 259 of Maine’s 7,500 prescribers opted into the statute's confidentiality protection during the period in which it has been suspended by the preliminary injunction tells us little about the law’s likely impact. More activity presumably will occur once the injunction is lifted.

. The "subsidiary” nature of the out-of-state transactions is, of course, a function of the statute’s purpose to restrict speech in Maine. *46Although that in-state speech objective strengthens the State's Commerce Clause position, the indirect regulatory strategy — as I have explained — creates the First Amendment-Commerce Clause dance and unnecessarily complicates the constitutional analysis.

. The actual impact on the plaintiffs of legislation regulating the use of prescriber-identifiable data remains to be seen. As the district court noted, the law "does not prevent the pharmaceutical companies from marketing their products and the companies may resort to more general, less tailored marketing." Rowe, 532 F.Supp.2d at 174. It thus may be that the demand for aggregated data about prescribing trends will change, but not dry up. For example, the statute appears to permit detailers to use aggregated data based on specialties or zip codes. See Ayotte, 550 F.3d at 95 n. 66. Moreover, if empirical data gathered in the future on the statute's impact shows that less particularized, less efficient detailing is negating the cost savings Maine hopes to achieve, the State may be persuaded to change its approach to the problem. Cf. Clover Leaf Creamery Co., 449 U.S. at 473 n. 17, 101 S.Ct. 715 ("The existence of major instate interests adversely affected by [a law] is a powerful safeguard against legislative abuse.”).

. The district court in Sorrell observed that, “[b]y definition, the ‘Supreme Court's commercial speech doctrine ... creates a category of speech defined by content but afforded only qualified protection.’ ” 631 F.Supp.2d at 447-48 (quoting Trans Union Corp. v. FTC, 267 F.3d 1138, 1141-42 (D.C.Cir.2001)).

. The district court in Vermont also was faced with competing arguments about “the nature and amount of deference” that should be afforded to "the predictive judgments and factual findings of the Legislature.” Sorrell, 631 F.Supp.2d at 448-49.