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States Join Fight to Lower Prescription Prices

Faced with rising prescription drug prices, dozens of states have moved aggressively over the past year to propose ways to turn back the tide.

That's not just out of the goodness of their hearts. States themselves are hit by drug costs via public employee health plans, Medicaid and other programs.

"States have balanced budgets, and they're reeling from unpredictable and rapid drug price increases,” says Trish Riley, executive director of the National Academy for State Health Policy (NASHP), a group of policymakers. Fixes at the federal level might not be speedy enough, she says. “States can't wait."

Last year state legislators introduced 178 bills related to prescription drug costs, the NASHP reports. In the first three months of 2019, 220 such bills were filed in 43 states, Riley says.

But only a fraction of bills ever become law. And in February activists suffered a setback: The U.S. Supreme Court let stand a lower court decision striking down a Maryland law that would have let the state prosecute generic drugmakers for “unconscionable” price hikes. The lower court had ruled that the law, endorsed by AARP Maryland, violated the constitutional prohibition against states regulating commerce beyond their borders.

The ruling did not bode well for similar bills that had been introduced in a dozen other states. But it may have a silver lining.

"It was a rallying cry,” says Elaine Ryan, AARP's vice president of state advocacy and strategy integration. “Our state office and advocates are back trying to formulate a law that will actually pass muster."

Here are some of the most promising state-level tactics for reining in drug costs.

Bills aimed at different aspects of the drug-price problem:

AARP/NASHP - Numbers as of March 29, 2019

Rate ceilings

Some policymakers want to establish affordability commissions that would set payment ceilings for some expensive brand-name or biologic drugs. Insurers would typically not be permitted to pay more than the amount set for such drugs. These bills have already been introduced this year in 14 states, including Maryland, Minnesota and New Jersey.

Supply-chain oversight

The largest number of state bills filed in 2019 would regulate pharmacy benefit managers, the corporate middlemen that administer drug plans for insurers or companies. PBMs — often at odds with drug companies for their role in negotiating prices for insurers — have come under fire for pricing and other practices. Legislators had filed 96 bills in this area by March 29, according to the NASHP. Also popular are “transparency bills” that would require manufacturers, insurers or PBMs to disclose drug prices or other information.

Drug Importation

In February, Florida Gov. Ron DeSantis made a splash when he proposed allowing his state to import prescription drugs wholesale from Canada. Vermont enacted such a law last year, and a handful of other states have considered this approach. But it requires federal approval, which Vermont has yet to obtain.

But importing drugs from Canada has its limits. “We can't rely on the Canadian health care system to fill all the gaps for us,” says Stacie B. Dusetzina, an associate professor of health policy at Vanderbilt University School of Medicine in Nashville, Tenn. “[Canada] may not have the supply to do so if more states decided that importation is a good solution."

Bulk Purchasing

California Gov. Gavin Newsom has another plan: leveraging the buying power of his state — by far the most populous in the nation — to negotiate with drug companies when buying drugs for the state Medicaid program, prisons and government workers, among other groups. Still in the proposal stage, the idea has attracted the interest of other states, which may join forces with California.

By the end of March, seven of the 220 bills filed in 2019 had become law. Last year five states approved new laws related to transparency. And 27 states passed laws prohibiting PBMs from imposing gag clauses that prevent pharmacists from telling consumers about cheaper drug options, says Katie Gudiksen, a senior health policy researcher at The Source on Healthcare Price & Competition. In an indication that policymakers at the national level can think along the same lines, President Trump signed two federal laws establishing gag clause protections as well.

Michelle Andrews, AARP, April 30, 2019 

Beware of Stand Alone Emergency Rooms!

A few months ago, my son went on a camping trip with his Dad.  The camping experts on the trip had prepared a great meal using cast iron dutch ovens and had removed the lids and placed the hot coals next to the fire to cool. 

My son was barefoot and stepped right on one of those hot coals. Ouch!

By the next day (a Sunday) when they came home, he had a huge blister that covered about a third of the sole of his foot. It was very red and mottled - an indication of a 2nd degree or worse burn.

Being a Mom, I naturally panicked and took him immediately to one of those 24-hour stand-alone emergency rooms because our normal urgent care facility was closed.  The doctor at the ER took a look at it, put some burn ointment on it, wrapped it up and sent us home - with instructions to see his regular doctor the next day.

At the ER, they cautioned me that they were not an urgent care facility and the copay was three times as much as an urgent care facility.  Although I didn't like the extra copay, I assumed other charges would be similar to the urgent care.  Well, that was not the case.  They immediately billed my insurance company for over $3,000 worth of emergency accident services, surgery, and supplies (more about this later).

My insurance company sent us a statement documenting that the stand alone ER is not considered "in network", while a regular ER adjoining a hospital would be.  By not being "in network" the copay doubled (remember it had already been tripled) and the provider could choose whether or not to include any discounts normally applied for the insurance.  Our insurance company stated that we may owe the provider over $2,000. 

Fortunately for us, the provider opted to allow the discounts and we ultimately were only billed for around $550 altogether...whew!  This is the reason why I decided not to dispute the "surgery" charge for wrapping the wound in gauze.  In other words, I decided to "let sleeping dogs lie".

FYI, here is a link to an article about urgent care vs free standing emergency rooms: 

You Thought It Was An Urgent Care Facility Until You Got The Bill 

Take Advantage of Virtual Doctor Options!

Although that was a stressful lesson to learn, there was another option that our insurance company provides, free of charge, that we should have taken advantage of - the "virtual doctor".  With this option, you can contact a board-certified physician 24 hours a day, 7 days a week by phone or computer, to obtain a diagnosis and/or opinion on medical treatment.  Prescriptions can be sent to pharmacies and we could have gotten the same advice, free of charge.  Annoyingly, our insurance card states that very clearly on the front of the card.  Live and learn!

FYI, here is a link to an article about “virtual healthcare” services in general:

What is Virtual Healthcare and How Does It Fit Into Telehealth

Anne Dobbs, Office Manager, Arrowhead Asset Management

“Affordable” Health Insurance vs Health Care

There is no such thing as affordable health insurance, because on a purely moral basis, no one should have to pay for administration costs to deny coverage, and to generate a profit for such a universal basic human need.

Insurance 101 teaches us that making small regular payments to build up a buffer for a large emergency expense is a good and prudent idea, even if that large expense never materializes. On a personal level this is called self-insurance. So why don’t we all just insure ourselves?

Clearly, the wages most people make, and the costs of modern health care, do not balance out. A group of people making regular payments can pay for a wide array of services for the entire group, including a few very expensive ones, as long as there are some very healthy people paying in to build up a large enough fund. Additionally, a large fund can be managed professionally to generate interest through short term investments to help grow the fund. The larger the group, the better this works.

The largest group we have in the US is, in fact, the entire population, from infants to elders. For-profit insurance divides this larger group and attempts to cherry pick healthy members to avoid the most expensive cases. Government subsidies designed to cover the least desirable members for the industry go to the industry, not the patients.

The ACA, for all of its immediate benefits for a small subset of the population is a Heritage Foundation, right/moderate-republican wing plan that should be called RomneyCare. The efforts of Max Baucus in heading the ACA creation, who was allowed by Barack Obama to ignore any kind of public option, were directly supported by the Health Insurance and Drug lobbies to maintain their stranglehold on Health Care in America.

Health Care is the delivery of services to those in need. Progressive services include wellness education and prevention. They can bring the total group expenses down, but nothing can reduce the costs as well as removing wasteful administration and profit. Large non-profit health groups keep administration at less than 3% of costs compared to 35% overhead and profit of many pre ACA plans, and the 20% cap with the ACA.

There is nothing new about universal non-profit Health Care, except in the US. Every other major country has it and in many places for-profit health insurance is illegal.

The term litmus test to choose candidates is cliché and actually debases the argument to one of political correctness of choice. Logic, reason, and the very basis of Capitalist thought says that a more efficient, better quality service or product will beat the competition and creative destruction will sweep away the weaker player.

A 40% cheaper product that works for everyone and provides improved outcomes is the hands-down winner. The way we pay for it? We stop paying for insurance. Single payer, Medicare for All, is the cleaver that will divide the 2020 candidate field.

An Americanized Version of Canada's Health Care System is the Only Sensible Way

Costly complexity is baked into Obamacare. No health insurance system is without problems but Canadian-style single-payer— full Medicare for all— is simple, affordable, comprehensive and universal.

In the early 1960s, President Lyndon Johnson enrolled 20 million elderly Americans into Medicare in six months. There were no websites. They did it with index cards!

Replace the current chaotic American system with a much more efficient Americanized version of Medicare-for-all: everybody in, nobody out, free choice of doctor and hospital. It will produce far less anxiety, dread, and fear.

Here are 25 reasons the Canadian health care system is better than the chaotic U.S. system:

Number 25:

In Canada, everyone is covered automatically at birth – everybody in, nobody out.

In the United States, even under Obamacare, 28 million Americans (9 percent) are still uninsured.

Number 24:

In Canada, the health system is designed to put people first, profits (or a sustainable budget), second.

In the United States, Obamacare has done little to curb insurance industry profits and in fact has increased the concentrated insurance industry’s massive profits.

Number 23:

In Canada, coverage is not tied to a job or dependent on your income – rich and poor are in the same system, the best guaranty of quality.

In the United States, even under Obamacare, much still depends on your job or income. Lose your job or lose your income, and you might lose your existing health insurance or have to settle for lesser coverage.

Number 22:

In Canada, health care coverage stays with you for your entire life.

In the United States, even under Obamacare, for tens of millions of Americans, health care coverage stays with you for as long as you can afford your insurance.

Number 21:

In Canada, you can freely choose your doctors and hospitals and keep them. There are no lists of “in-network” vendors and no extra hidden charges for going “out of network.”

In the United States, even under Obamacare, the in-network list of places where you can get treated is shrinking – thus restricting freedom of choice – and if you want to go out of network, you pay dearly for it.

Number 20:

In Canada, the health care system is funded by income, sales and corporate taxes that, combined, are much lower than what Americans pay in insurance premiums directly and indirectly per employer.

In the United States, even under Obamacare, for thousands of Americans, it’s pay or die – if you can’t pay, you die. That’s why many thousands will still die every year under Obamacare from lack of health insurance to get diagnosed and treated in time.

Number 19:

In Canada, there are no complex hospital or doctor bills. In fact, usually you don’t even see a bill.

In the United States, even under Obamacare, hospital and doctor bills are terribly complex, making it very difficult to discover the many costly overcharges or massive billing fraud.

Number 18:

In Canada, costs are controlled. Canada pays 10 percent of its GDP for its health care system, covering everyone.

In the United States, even under Obamacare, costs continue to skyrocket. The U.S. currently pays 17.9 percent of its GDP and still doesn’t cover tens of millions of people.

Number 17:                                       

In Canada, it is unheard of for anyone to go bankrupt due to health care costs.

In the United States, health-care-driven bankruptcy will continue to plague Americans.

Number 16:

In Canada, simplicity leads to major savings in administrative costs and overhead.

In the United States, even under Obamacare, often staggering complexity leads to ratcheting up huge administrative costs and overhead.

Number 15:

In Canada, when you go to a doctor or hospital the first thing they ask you is: “What’s wrong?”

In the United States, the first thing they ask you is: “What kind of insurance do you have?”

Number 14:

In Canada, the government negotiates drug prices so they are more affordable.

In the United States, even under Obamacare, Congress made it specifically illegal for the government to negotiate drug prices for volume purchases, so they remain unaffordable and skyrocketing.

Number 13:

In Canada, the government health care funds are not profitably diverted to the top one percent.

In the United States, even under Obamacare, health care funds will continue to flow to the top. In 2017, the CEO of Aetna alone made a whopping $59 million.

Number 12:

In Canada, there are no required co-pays or deductibles in inscrutable contracts.

In the United States, even under Obamacare, the deductibles and co-pays will continue to be unaffordable for many millions of Americans.

Number 11:

In Canada, the health care system contributes to social solidarity and national pride.

In the United States, even Obamacare is divisive, with rich and poor in different systems and tens of millions left out or with sorely limited benefits.

Number 10:

In Canada, delays in health care are not due to the cost of insurance.

In the United States, even under Obamacare, patients without health insurance or who are underinsured will continue to delay or forgo care and put their lives at risk.

Number 9:

In Canada, nobody dies due to lack of health insurance.

In the United States, tens of thousands of Americans will continue to die every year due to lack of health insurance and much higher prices for drugs, medical devices, and health care itself.

Number 8:

In Canada, health care on average costs half as much, per person, as in the United States. And in Canada, everyone is covered.

In the United States, a 60% majority support Medicare-for-all.

Number 7:

In Canada, the tax payments to fund the health care system are modestly progressive – the lowest 20 percent pays 6 percent of income into the system while the highest 20 percent pays 8 percent.

In the United States, even under Obamacare, the poor pay a larger share of their income for health care than the affluent.

Number 6:

In Canada, people use GoFundMe to start new businesses.

In the United States, fully one in three GoFundMe fundraisers are now to raise money to pay medical bills. Recently, one American was rejected for a heart transplant because she couldn’t afford the follow-up care. Her insurance company suggested she raise the money through GoFundMe.

Number 5: 

In Canada, people avoid prison at all costs.

In the United States, some Americans commit minor crimes so that they can get to prison and get free health care.

Number 4: 

In Canada, people look forward to the benefits of early retirement.

In the United States, people delay retirement to 70-75 to avoid being uninsured.

Number 3:

In Canada, Nobel Prize winners hold on to their medal and pass it down to their children and grandchildren.

In the United States, Nobel Prize winners sell their medals to pay for their medical bills.

Leon Lederman won a Nobel Prize in 1988 for his pioneering physics research. But in 2015, the physicist, who passed away in November 2018, sold his Nobel Prize medal for $765,000 to pay his mounting medical bills. According to a report in Vox, the University of Chicago professor began to suffer from memory loss in 2011, and died in an Idaho nursing home.

Number 2: 

In Canada, the system is simple. You get a health care card when you are born. And you swipe it when you go to a doctor or hospital. End of story.

In the United States, Obamacare’s absurd 2,500 pages plus regulations (the Canadian Medicare Bill was 13 pages) is so complex that then Speaker of the House Nancy Pelosi said before passage “we have to pass the bill so that you can find out what is in it, away from the fog of the controversy.”

Number 1: 

In Canada, the majority of citizens love their health care system.

In the United States, a growing majority of citizens, physicians, and nurses now prefer the Canadian type system – Medicare-for-all, free choice of doctor and hospital , everybody in, nobody out and far less expensive.

It’s now only a matter of time!

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