Some 'Cheaper' Health Plans Have Surprising Costs
One health insurance startup charges patients extra for procedures not covered by their basic health plan. The out-of-pocket cost for a tonsillectomy and adenoidectomy might range from $900 to $3,000 extra, while a lumbar spine fusion could range from $5,000 to $10,000.
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One health plan from a well-known insurer promises lower premiums — but warns that consumers may need to file their own claims and negotiate over charges from hospitals and doctors. Another does away with annual deductibles — but requires policyholders to pay extra if they need certain surgeries and procedures.
Both are among the latest efforts in a seemingly endless quest by employers, consumers and insurers for an elusive goal: less expensive coverage.
Premiums for many of these plans, which are sold outside the exchanges set up under Affordable Care Act, tend to be 15 to 30 percent lower than conventional offerings, but they put a larger burden on consumers to be savvy shoppers. The offerings tap into a common underlying frustration.
“Traditional health plans have not been able to stem high cost increases, so people are tearing down the model and trying something different,” said Jeff Levin-Scherz, health management practice leader for benefit consultants Willis Towers Watson.
Not everyone is eligible for a subsidy to defray the cost of an ACA plan, and that has led some people to experiment with new ways to pay their medical expenses. Those experiments include short-term policies or alternatives like Christian-sharing ministries — which are not insurance at all, but rather cooperatives through which members pay one another’s bills.
Now some insurers — such as Blue Cross Blue Shield of North Carolina and a Minnesota startup called Bind Benefits, which is partnering with UnitedHealth Group — are coming up with their own novel offerings.
Insurers say the two new types of plans meet the ACA’s rules, although they interpret those rules in new ways. For example, the new policies avoid the federal law’s rule limiting consumers’ annual in-network limit on out-of-pocket costs. One policy manages that by having no network — patients are free to find providers on their own. And the other skirts the issue by calling additional charges “premiums.” Under ACA rules, premiums don’t count toward the out-of-pocket maximum.
But each plan could leave patients with huge costs in a system in which it is extremely difficult for a patient to be a smart shopper — in part, because they have little negotiating power against big hospital systems and partly because illness is often urgent and unanticipated.
If these alternative plans prompt doctors and hospitals to lower prices, “then that is worth taking a closer look,” says Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. “But if it’s simply another flavor of shifting more risk to employees, I don’t think in the long term, that’s going to bend the cost curve.”
Balancing freedom, control and responsibility
The North Carolina Blue Cross Blue Shield “My Choice” policies aim to change the way doctors and hospitals are paid by limiting reimbursement for services to 40 percent above what Medicare would pay. The plan has no specific network of doctors and hospitals.
This approach “puts you in control to see the doctor you want,” the insurer says on its website. The plan is available to individuals who buy their own insurance and to small businesses with one to 50 employees. It’s aimed at consumers who cannot afford ACA plans, says Austin Vevurka, a spokesman for the insurer. The policies are not sold on the ACA’s insurance marketplace, but can be purchased off-exchange from brokers.
With that freedom, however, consumers also have the responsibility to shop around for providers who will accept that amount of reimbursement for their services. Consumers who don’t shop — or can’t because their medical need is an emergency — may get “balance-billed” by providers who are unsatisfied with the flat amount the plan pays.
“There’s an incentive to comparison-shop to find a provider who accepts the benefit,” says Vevurka.
The cost of balance bills range widely but could be thousands of dollars in the case of hospital care. Consumer exposure to balance bills is not capped by the ACA for out-of-network care.
“There are a lot of people for whom a plan like this would present financial risk,” says Levin-Scherz.
In theory, though, paying 40 percent above Medicare rates could help drive down costs over time if enough providers accept those payments. That’s because hospitals currently get about double Medicare rates through their negotiations with insurers.
“It’s a bold move,” says Mark Hall, director of the health law and policy program at Wake Forest University in North Carolina. Still, he says, it’s “not an optimal way” because patients generally don’t want to negotiate with their doctor on prices.
“But it’s an innovative way to put matters into the hands of patients as consumers,” Hall says. “Let them deal directly with providers who insist on charging more than 140 percent of Medicare.”
Blue Cross spokesman Vevurka says My Choice has telephone advisers to help patients find providers and offer tips on how to negotiate a balance bill. He would not disclose enrollment numbers for My Choice, which launched Jan. 1, nor would he say how many providers have indicated they will accept the plan’s payment levels.
Still, the idea — based on what is sometimes called “reference pricing” or “Medicare plus” — is gaining attention. Under that method, hospitals are paid a rate based on what Medicare pays, plus an additional percentage to allow them a modest profit.
North Carolina’s state treasurer, for example, hopes to put state workers into such a pricing plan by next year, offering to pay 177 percent of Medicare. The plan has ignited a firestorm of opposition from hospitals in the state.
Montana recently got its hospitals to agree to such a plan for state workers, paying 234 percent of Medicare, on average.
Partly because of concerns about balance-billing, employers aren’t rushing to buy into Medicare-plus pricing just yet, says Jeff Long, a health care actuary at Lockton Companies, a benefit consultancy.
Wider adoption, however, could spell its end.
Hospitals might agree to participate in a few such programs, but “if there’s more takeup on this, I see hospitals possibly starting to fight back,” Long says.
What about the bind?
Minnesota startup Bind Benefits eliminates annual deductibles in its “on-demand” plans sold to employers that are opting to self-insure their workers’ health costs. Rather than deductibles, patients pay flat-dollar copayments for a core set of medical services, from doctor visits to prescription drugs.
In some ways, it’s simpler: There is no need to spend through the deductible before coverage kicks in or wonder what 20 percent of the cost of a doctor visit or surgery would be.
But not all services are included.
Patients who discover during the year that they need any of about 30 common procedures outlined in the plan, including several types of back surgery, knee arthroscopy or coronary artery bypass, must “add in” coverage, spread out over time in deductions from their paychecks.
“People are used to that concept, to buy what they need,” said Bind CEO Tony Miller. “When I need more, I buy more.”
According to a company spokeswoman, the add-in costs vary by market, procedure and provider. On the lower end, the cost for tonsillectomy and adenoidectomy ranges from $900 to $3,000, while lumbar spine fusion could range from $5,000 to $10,000.
To set those additional premiums, Bind analyzes how much doctors and facilities are paid, along with some quality measures from several sources, including UnitedHealth. The add-in premiums paid by patients vary depending on whether they choose lower-cost providers or more expensive ones.
The ACA’s 2019 out-of-pocket maximums — $7,900 for an individual or $15,800 for a family — don’t include premium costs.
The Cumberland School District in Wisconsin switched from a traditional plan, which it purchased from an insurer for about $1.7 million last year, to Bind. Six months in, according to the school district’s superintendent, Barry Rose, the plan is working well.
Right off the bat, he says, the district saved about $200,000. More savings could come over the year if workers choose lower-cost alternatives for the “add-in” services.
“They can become better consumers because they can see exactly what they’re paying for care,” Rose says.
Levin-Scherz at Willis Towers says the idea behind Bind is intriguing but raises some concerns for employers.
What happens, he asks, if a worker has an add-in surgery, owes several thousand dollars, then changes jobs before paying all the premiums for that add-in coverage? “Will the employee be sent a bill after leaving?” he wonders.
A Bind spokeswoman says the former employee would not pay the remaining premiums in that case. Instead, the employer would be stuck with the bill.
Kaiser Health News is a nonprofit news service and editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.
U.S. Cities Skeptical Of FDA Warnings Against Medicine Imports From Canadian Firm
The Food and Drug Administration suggests consumers who get prescription drugs mailed to them via CanaRx are at risk of getting mislabeled or counterfeit drugs. But consumer watchdog groups say the FDA has supplied no evidence that’s happened.
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Cities and local governments in several states say they will continue to use a Canadian company to offer employees prescription drugs at a highly reduced price, even though officials from the U.S. Food and Drug Administration have raised safety concerns about the practice.
The municipalities use CanaRx, which connects their employees with brick-and-mortar pharmacies in Canada, Great Britain and Australia to fill prescriptions.
In a letter sent last week to CanaRx, the FDA said the company has sent “unapproved” and “misbranded” drugs to U.S. consumers, jeopardizing patient safety.
The FDA also urged consumers not to use any medicines from CanaRx, which works with about 500 cities, counties, school districts and private employers in the United States to arrange drug purchases. Some of these employers started using the service as far back as 2004.
Prices of drugs from overseas pharmacies can be as much as 70 percent lower than what people pay in the U.S. because the costs are regulated by the foreign governments.
FDA officials would not explain why they waited more than a decade to act. They acknowledged the agency had no reports of anyone harmed by drugs received through CanaRx.
The FDA made its warning as Congress and the Trump administration look into ways to lower drug prices. Last month, Florida Republican Gov. Ron DeSantis said he has President Donald Trump’s backing to start a program to begin importing drugs from Canada for state residents.
After DeSantis’ comments, White House officials stressed that any such plan must get state and federal approvals.
The FDA says that in most cases importing drugs for personal use is illegal, although it very rarely has tried to stop Americans from bringing drugs across the Canadian border. It has not stopped retail stores in Florida that have helped consumers buy drugs from Canada since 2003. Nine storefronts were raided by FDA officials in 2017, although the FDA has allowed them to continue operating.
Schenectady County in New York, which has worked with CanaRx since 2004, defended its relationship and has no immediate plans to end it, according to Chris Gardner, the county attorney. “We will wait to see how this plays out, but right now it’s status quo,” Gardner says.
He says CanaRx, which is headquartered in Windsor, Ontario, helped the county save $500,000 on drug costs in 2018. About 25 percent of the county’s 1,200 workers use the program and get their drugs with no out-of-pocket costs. If they use American pharmacies, they generally have a copayment.
“This is a good program, and on the merits it looks lawful, and they are not doing the terrible things that the FDA is suggesting,” Gardner says.
CanaRx officials deny they have been breaking any laws or putting Americans’ health at risk. They say they are not an online pharmacy but a broker between U.S. employees and brick-and-mortar pharmacies in Canada, Australia and Great Britain. People can buy drugs via CanaRx only with a prescription from their doctor.
The company says it has no plans to stop distributing drugs.
“The FDA’s characterizations of the CanaRx business model and operating protocols are completely wrong,” says Joseph Morris, a Chicago-based lawyer for the company. “It is not possible to place an order via any CanaRx website; the websites are informational only.”
Morris says the FDA notice has prompted calls from many municipalities; but so far all say they plan to stick with the company.
The FDA warning says online pharmacies that purport to sell drugs from Canada, Britain and Australia may actually get their drugs from other countries, which would increase the risk consumers are dealing with counterfeit drugs.
CanaRx says that “it contracts with government-licensed physicians, pharmacists and pharmacies in Canada, the United Kingdom, and Australia … to supply brand name medications, packaged and sealed by the original manufacturer, for direct delivery to all participants.”
Gabriel Levitt is president of pharmacychecker.com, an independent website for U.S. consumers that verifies international pharmacies offering drugs online. He notes that the FDA’s warning letter offered no evidence CanaRx has distributed any counterfeit drugs since it began business almost 20 years ago.
Columbia County, N.Y., has been using CanaRx for about a decade and says the savings allows it to offer employees drugs with no out-of-pocket costs, instead of requiring them to pay as much as a $40 copay in local pharmacies.
“This is bull,” Stephen Acciani, an insurance broker who works with the county, says of the FDA crackdown. “They are not selling unsafe medications.” His recommendation would be for the county, which has more than 600 employees on its health plan, to continue using CanaRx.
Acciani notes that employees receive the medicine through the mail in its original packaging from the manufacturer.
“It will give some clients pause,” says Kate Sharry, a benefits consultant to the city of Fall River, Mass., and more than 100 other municipalities in the state. “How can you not pay attention to this from the FDA?” But she expects the local governments to stay with CanaRx.
Federal health officials under both Republican and Democratic administrations have blocked efforts to legalize importing medication, saying it’s too risky.
“Sometimes a bargain is too expensive,” says Peter Pitts, a former FDA associate commissioner (from 2000 to 2004)who is now president of the Center for Medicine in the Public Interest, a New York-based nonprofit that receives some of its funding from drugmakers.
Pitts, who applauds the FDA action, says it’s difficult for consumers to know when their pills from foreign pharmacies don’t have the correct potency or ingredients. He says doctors may also not realize a patient’s problem stems from issues with the medicine. Instead, the physicians may just change the medication’s dosage. He says it is not safe for Americans to buy drugs that are imported through foreign pharmacies.
Levitt says CanaRx is one of the safest ways for Americans to get drugs from legitimate pharmacies in Canada and other industrialized counties.
The FDA is likely trying to intimidate CanaRx and its clients in local government, Levitt says.
“My biggest fear is they will scare consumers, [who then] won’t take their very safe and effective medications because they hear about this bogus warning,” says Levitt.
“The FDA’s action,” he says, “which appears to try and make those programs look unsafe and sinister, seems to have a political and public relations purpose — one that is perfectly allied with the lobbying agenda of drug companies.”
Levitt points to testimony FDA Commissioner Scott Gottlieb gave to a House subcommittee last week — just a day before the CanaRx warning, and ahead of his announcement that he will be leaving the FDA next month.
When asked about importing Canadian drugs, Gottlieb did not mention CanaRx, but did say that people going to a “brick and mortar” pharmacy in Canada “are getting a safe and effective drug. I have confidence in the Canadian drug regulatory system.” He added that his concerns are with online pharmacies.
The Pharmaceutical Research and Manufacturers of America, the industry trade and lobbying group, has cheered the FDA action but denies it had any role in it, says spokeswoman Nicole Longo.
“PhRMA supports the FDA’s efforts to crack down on organizations that are circumventing its robust safety and efficacy requirements,” Longo says. “Drug importation schemes expose Americans to potentially unsafe, counterfeit or adulterated medicines.”
Kaiser Health News is a nonprofit news service and editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
How Much Is Today's HIV Research Centered Around The Search For A Cure?
For the second time ever, a man’s HIV infection has been sent into remission. NPR’s Mary Louise Kelly talks with Rowena Johnston, director of research for the Foundation for AIDS Research.
MARY LOUISE KELLY, HOST:
Today a big announcement about HIV/AIDS – a second man’s HIV infection is in remission. This is being hailed as a milestone in the search for a cure, which prompts a question. Decades into the epidemic with drugs available that prevent HIV infection and can treat it, how relevant is the search for a cure? We’re going to put that question to Rowena Johnston. She is in Seattle for the conference where this news was announced today. She’s the vice president and director of research for the Foundation for AIDS Research – amfAR. And she joined us from member station KUOW.
Rowena Johnston, welcome.
ROWENA JOHNSTON: Thank you very much.
KELLY: So I want to mention that your group amfAR funded the research, which is published today in the journal “Nature.” Talk to me about this specific case and why it’s a breakthrough. This has to do with a man with HIV and cancer who got a stem cell transplant.
JOHNSTON: That’s right. We’re referring to this man as the London patient. He was living in London and was living with HIV and developed cancer. And his cancer was not responding to normal treatments. And so he became a candidate for a stem cell transplant. And his physicians were really quite smart. And they decided to look for a donor who also had a CCR5-delta 32 mutation.
KELLY: OK.
JOHNSTON: And this mutation is quite rare, but people who have this mutation are highly resistant to HIV infection. And so by using cells from this donor, they were replacing the London patient’s immune system with the immune system of a person who’s highly resistant to HIV in a situation that was very closely similar to the Berlin patient, who we now do believe was cured.
KELLY: Between these two patients was – I believe it’s a dozen years. And doctors had, of course, tried to replicate the results in those intervening years. And the virus kept coming back. Do we know why it was successful with this new patient, with this London patient?
JOHNSTON: You’re right that there had been attempts to recapitulate what had happened in the Berlin patient. In some cases, the transplant recipients were getting donor cells from a person who did not have that CCR5-delta 32 genetic mutation. So it’s beginning to look like having donors that have that mutation is a key element to this successful outcome. So it’s really having the similarities and the differences between these cases and being able to compare them is where we’re going to learn the valuable lessons to move us forward.
KELLY: Just to be clear, the London patient was dealing with a very specific health situation. In other words, the breakthrough that is being reported today does not mean that a widespread, universal cure is within immediate reach. Is that right?
JOHNSTON: That’s right. Stem cell transplant is only appropriate for people who are living with a cancer of the immune system. So this intervention itself is not the way in which we are going to cure people living with HIV across the world. What this intervention is going to help us understand, though, is which are the critical components that we can learn from and put together so that we can develop some different type of cure that is appropriate everywhere that people are living with HIV.
KELLY: So let me circle you back to the question I posed at the outset, which is we – now decades into this grappling with HIV and AIDS, there are drugs which help prevent infection, which help people who are living with HIV infection manage it and live successful, long lives at this point. Why is it so important to find a cure?
JOHNSTON: A person living with HIV today needs to take their antiretroviral therapy every single day of their lives for the rest of their lives. And that becomes very burdensome both from an economic perspective and also, perhaps, from the perspective of their own health. And when you’re taking antiretroviral therapy every day, you’re reminded every day that you have this virus for which you are stigmatized.
And so having a cure for HIV relieves a lot of these burdens. And if we can cure this infection, that’s going to encourage people to get tested for HIV because there’s going to be that sense of optimism that they don’t have to live with this virus for the rest of their lives.
KELLY: Rowena Johnston – she is research director for amfAR. That’s the Foundation for AIDS Research. Thanks for your time.
JOHNSTON: Thank you very much.
Copyright © 2019 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.
NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.
Governments Struggle To Find A Way To Pay Retirement Pension Bills
There’s a growing fiscal crisis hitting cities, counties and states across the U.S. It’s all about generous retiree health benefits that historically haven’t been fully funded.
MICHELE MARTIN, HOST:
Across the United States, there is a growing problem for current and retired government employees. It has to do with retiree packages known as other postemployment benefits. They’ve been around for decades, but they are often chronically underfunded. And now with the retirement of more baby boomers, it’s time to pay up. Houston Public Media’s Andrew Schneider reports on how one city is trying to head off a financial crisis.
ANDREW SCHNEIDER, BYLINE: Any city council meeting can be boring, especially when it’s about finances. But in Houston, those meetings and what they’re wrestling with have forced people to sit up and take notice.
DAVID BERGER: Our initial $2.4 billion liability has been mentioned, but we projected it out over the next 30 years, and it became $9 billion.
SCHNEIDER: David Berger of Segal Consulting talked about the bleak financial outlook for Houston, the nation’s fourth largest city. He says that $9 billion projected shortfall is a real problem.
BERGER: That would increase far faster than your revenues, your tax revenues. And so that kind of highlights the need for, not only a current solution, but a longer term. What can we do to control the longer term costs as well?
SCHNEIDER: Houston is far from alone. The Center for Retirement Research at Boston College has been looking at this issue. In 2016, it found that cities counties and states collectively are short more than $860 billion.
ALICIA MUNNELL: The problem is nationwide. The seriousness of the problem varies a lot.
SCHNEIDER: Alicia Munnell is the center’s director. Historically, governments have always underfunded pensions and retiree benefits. But it’s not been until the last few years that federal accounting rules forced them to admit the shortfalls. And Munnell says some states are really struggling.
MUNNELL: I’m not going to surprise you very much. Illinois, Connecticut, New Jersey, those are the plans where you see the most serious shortfalls and where you have, you know, high debt service and high retiree health care costs as well.
SCHNEIDER: In terms of local governments, she points to counties in California and cities like Chicago and Detroit. And then there’s Houston. It’s proposing some drastic measures to keep retiree benefits from mushrooming into another crisis. Councilman Dave Martin says they’re looking into eliminating some spousal subsidies depending on longevity.
DAVE MARTIN: We have some retirees that are marrying younger men and women – for instance, a 50-year-old man marries a 30-year-old woman or a 50-year-old woman marries a 30-year-old man. The obligation in the retirement goes with the younger spouse.
SCHNEIDER: Houston officials are worried that some of these changes, which include no postretirement health coverage for new employees, could make it more difficult to attract workers to the city. Bill Fulton directs the Kinder Institute for Urban Research at Rice University. Fulton says unfunded retiree benefits could lead to the same problems for cities that had unfunded pensions.
BILL FULTON: Where we’ve seen bankruptcies so far have been purely a pension problem. That was the problem in Detroit. I do think that we – there will be – I can’t say which ones – but I do think probably some jurisdictions will be at similar financial risk as postemployment benefits become a bigger issue and become more expensive.
SCHNEIDER: It’s a painful choice to make because when the benefits get more expensive, something else in the budget doesn’t get funded. The Houston City Council is expected to vote on the proposal to overhaul retiree benefits soon. For NPR News, I’m Andrew Schneider in Houston.
(SOUNDBITE OF HYPNOTIC BRASS ENSEMBLE’S “BALLICKI BONE”)
Copyright © 2019 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.
NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.
Texas Sharpens Aim At Surprise Medical Bills In Bipartisan Proposal
The proposed legislation aims to reduce patients’ costs by beefing up a Texas Department of Insurance program that scrutinizes surprise balance bills greater than $500 from any emergency health care provider.
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A bipartisan group of Texas lawmakers announced plans this week to address surprise medical bills in a way they believe would ease the burden on patients in the state.
During a news conference Thursday, state Sen. Kelly Hancock, a Republican from suburban Fort Worth, announced he had filed a bill in the Texas Legislature aimed at preventing medical providers from, among other things, balance billing patients — charging patients the difference between what the health care provider and the medical insurer think a medical service or procedure is worth. State Rep. Trey Martinez Fischer, a Democrat from San Antonio, is filing a similar bill in the House.
If passed, the legislation would force medical providers and health insurers to mediate payment disputes before they send bills to patients. Hancock said the point of SB 1264 is to take “the burden off of patients.”
“[It] takes it off of their plates completely,” Hancock said.
He highlighted the case of Drew Calver, a public school teacher in Austin whose six-figure hospital bill after a heart attack was featured in a “Bill of the Month” investigation last summer by NPR, Kaiser Health News and KUT, NPR’s member station in Austin. Hancock noted Calver’s bill was reduced after the media attention but said it shouldn’t take such attention for a patient to get a reasonable bill.
Under this legislation, both sides of the payment dispute would settle their issues through an existing balance bill mediation program. The Texas Department of Insurance program has been successful in lowering medical bills across the state.
The legislation would beef up the program, which addresses surprise balance bills greater than $500 from all emergency providers — including free-standing emergency departments and all out-of-network providers working at a network facility.
“This is designed to apply in situations where patients don’t have any choice which facility they go to or which physician is involved in their care,” Hancock said.
Historically, the Insurance Department’s mediation program had many loopholes, and few consumers qualified for help. It was expanded in 2017, though, and more patients have been filing complaints.
For example, in 2014, the department was asked to mediate 686 medical bills. During the 2018 fiscal year, it received 4,445 bills.
Hancock said the program, so far, has saved Texas patients $30 million.
Still, consumer advocates argue, the system works only when patients know mediation is an option.
Stacey Pogue, a senior policy analyst with the Center for Public Policy Priorities, said patients don’t always know help is available, or they find the process intimidating.
“The instructions for how to do it are on your medical bill and your explanation of benefits — the most indecipherable documents you are going to get,” she told KUT earlier this year.
She and others have argued Texas should adopt a program similar to those in other states like New York, California and Florida, whose systems are more consumer-friendly.
Martinez Fischer said it’s time Texas officials stepped in to help patients who are caught in the middle of disputes between medical providers and health insurers. “It has been an industry issue for a few years, I grant you that — the health plans and the providers fighting over their business interests,” he said. “And I respect that. But 10 years later, it is a consumer issue.”
Among other things, Hancock’s bill would allow people with federally regulated, self-funded health plans to opt into the state’s mediation program. According to Hancock, those plans make up about 40 percent of Texas’ insurance market, but those consumers are currently not able to take part in the program.
Hancock said this should provide relief to consumers while federal lawmakers weigh their own efforts to address surprise medical bills.
“Texas will send a loud and clear signal to D.C. that similar consumer protections need to be passed at the federal level,” Hancock said. “Until then, Texas … [is] committed to doing something about it.”
U.S. Rep. Lloyd Doggett, a Democrat who represents Austin in Congress, said he is encouraged by Texas’ efforts but called federal protections “essential.”
“Only approval in Congress of legislation like my End Surprise Billing Act can both protect those who work for large employers with self-funded, federally regulated ERISA plans and assure that patients across America are not forced to pay the price for conflicts between insurers and health care providers,” Doggett said in a written statement.
This story is part of NPR’s reporting partnership with KUT and Kaiser Health News, an editorially independent news service of the Kaiser Family Foundation. You can follow Ashley Lopez on Twitter: @AshLopezRadio
Foes Of Trump's Restrictions On Family Planning Clinics See Law On Their Side
Abortion-rights activists gathered for a news conference in New York City Monday to protest the Trump administration’s proposed restrictions on family planning providers. The rule would force any medical provider receiving federal assistance to refuse to promote, refer for, perform or support abortion as a method of family planning.
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State attorneys general and women’s health advocates who are hoping to block in court new Trump administration rules for Title X, the federal family planning program, face one major obstacle: The Supreme Court upheld very similar rules in 1991.
Those rules were summarily canceled after a change in administrations. But the court is arguably more conservative than it was 28 years ago.
Still, those who oppose the Trump administration’s rules say that the ground has shifted. They expect to succeed in court this time, they say — pointing to protections enacted in the 2010 Affordable Care Act and changes made by Congress in the mid-1990s in bills that fund Title X.
“I don’t file a lawsuit unless I’m confident we will prevail,” Washington state Attorney General Bob Ferguson said at a news conference Monday, as he announced his plans to sue the Trump administration over the changes to the program. “We’ve filed 17 cases against this administration,” Ferguson said. “We have not lost a case yet.”
The new rules for Title X, posted Friday by the Department of Health and Human Services, are aimed primarily at evicting Planned Parenthood from the program — a longtime goal of abortion opponents. Currently no Title X money can be used for abortions. But conservative groups argue that since many Planned Parenthood affiliates receiving Title X support also provide abortions, the federal family planning money could be improperly commingled with funds used for the procedure.
Planned Parenthood affiliates serve about 40 percent of the program’s 4 million patients.
Specifically, Trump’s rules would forbid family planning providers in almost all cases from referring pregnant patients for abortion. It also would rescind previous regulations that require providers to give women with unintended pregnancies “nondirective” counseling about all their options. “Nondirective” counseling has meant that providers can neither encourage nor deter women from any specific action. Women’s health advocates, including Planned Parenthood, argue that changing that provision, as the Trump administration wants to, would hamper physicians and other providers from giving women unbiased advice, which they say is a violation of medical ethics.
The new regulations also would require any providers that also perform abortions to make those facilities physically and financially separate from their clinics that receive federal funds.
Planned Parenthood has not specifically announced that it will sue, but Dr. Leana Wen, the organization’s president, was clear last week in a call with reporters that “Planned Parenthood cannot participate in a program that would force our providers to compromise their ethics.”
And several other lawsuits are being lined up in anticipation of the rules’ formal publication in the Federal Register, expected next week.
The American Civil Liberties Union announced it will sue on behalf of the National Family Planning & Reproductive Health Association, which represents publicly funded family planning providers and administrators, as well as the Cedar River Clinics in Washington state. The Center for Reproductive Rights has said it will sue on behalf of family planning providers in Maine.
Several other state officials have said that they will sue, including officials in New York, Oregon and California.
Proponents of the administration’s move point to the 1991 Supreme Court case Rust v. Sullivan as proof that the rules are constitutional. In a 5-4 decision, the court said that very similar regulations issued by the Reagan administration in 1988 were an acceptable exercise of executive authority and did not violate the underlying law or the U.S. Constitution.
Although the rules were upheld, subsequent legal action meant they were in effect only for a month before again being blocked and then rescinded by President Bill Clinton in 1993.
Alliance Defending Freedom, a law firm that opposes abortion, released a statement regarding Trump’s new Title X rules that said, in part: “The Protect Life Rule, which the U.S. Supreme Court has upheld, will prevent organizations like the nation’s largest abortion business, Planned Parenthood, from funding their abortion activities through the Title X program.”
Opponents of the new rules, however, insist that the situation has changed in the years since that Supreme Court decision. For one thing, argued several members of Congress in a letter to HHS earlier this month, the department may have violated the federal Administrative Procedure Act that governs the crafting of regulations.
For example, the letter said, HHS “declined to deem the Title X rule economically significant — completely disregarding the considerable health-related costs the rule would impose — and failed to conduct a comprehensive regulatory impact analysis.”
And while the top court is more conservative than it was in 1991, “there are two new developments,” Washington Assistant Attorney General Jeff Sprung told reporters; “two statutes passed by Congress, that impose new requirements.”
One of those statutes involves language added to the spending bill that funded HHS in 1995 and was renewed in subsequent years. It restates the ban on using family planning funds for abortion, but also stipulates that “all pregnancy counseling be nondirective.”
In 2010, the Affordable Care Act added to that, with language that, among other things, bars HHS from issuing any regulation that “interferes with communications regarding a full range of treatment options between the patient and the provider” or that “restricts the ability of health care providers to provide full disclosure of all relevant information to patients making health care decisions.”
Leah Litman, an assistant professor of law at the University of California, Irvine, said the now more conservative Supreme Court might not necessarily accept those arguments, as well as others likely to be raised.
But there is no question, she said, that “the underlying scope of [the Title X program] has changed” since 1991.
Julie Rovner is chief Washington correspondent for Kaiser Health News, a nonprofit news service, which is an editorially independent program of the Kaiser Family Foundation and not affiliated with Kaiser Permanente.
Bill That Would Regulate Doctors' Care Of Babies Who Survive Abortions Fails In Senate
The Senate failed to advance a bill that would regulate doctors’ care of babies who survive abortions. NPR’s Mary Louise Kelly talks with Washington Post reporter Mike DeBonis about the vote.
MARY LOUISE KELLY, HOST:
Yesterday, the Senate took up a bill that would have made sure doctors provide care for any child that survives an abortion. Fifty-three senators supported the bill, including three Democrats. That is not the 60 votes needed to avoid a filibuster, so the bill fails to advance. But even so, this issue is not likely to go away any time soon. The president offered his take soon after the vote, saying Democrats, quote, “don’t mind executing babies.” Here to discuss the bill and the politics behind it is Mike DeBonis. He covers Congress for The Washington Post, and he joins us now. Hey, Mike.
MIKE DEBONIS: Hey, Mary Louise. Thanks for having me.
KELLY: So what would this bill have done?
DEBONIS: Well, what it would’ve done would be to write into federal law that doctors, any health care provider would have to provide the same care to a child born after an attempted abortion that they would provide to any child born at the same gestational age. That is at the same time both very specific about what it requires doctors to do, which is do something – do the same as you would for another child, and it’s also very vague. It doesn’t say any particular type of intervention.
KELLY: So this prompts the question – is it clear that this law is needed to protect newborn lives? The sponsor of the bill, Senator Ben Sasse, Republican, and other Republican supporters of the bill say, yes, this is needed. This is about preventing doctors from committing infanticide.
DEBONIS: Well, there is a very strong dispute over how frequently these sorts of situations arise. Ben Sasse and other supporters of the bill say there are many occasions at which, after abortions, there are these children born alive. On the other hand, people opposing this bill say that these circumstances are exceedingly rare. And when they do happen, that these are in circumstances where you either have the life or health of the mother at stake, or you have a fetus, a child who is not likely to survive outside the womb for any length of time. And basically, their argument is that you are perhaps impairing a doctor’s best judgment at how to handle cases like this and that there are already standards and certainly laws in place to prevent infanticide, which is the word that the supporters of this bill keep using.
KELLY: And just to be clear, statistically, for a baby to survive in this situation, it needs to be fairly late stage in the pregnancy. And abortions performed at the very latest stages of pregnancy represent a small fraction of abortions overall.
DEBONIS: That’s right. We are talking about these very few cases that happen in the very latest stages of pregnancy.
KELLY: Give me a sense of what is happening on the state level in Virginia and New York, for example, that has led to this being debated at the national level.
DEBONIS: Sure. In New York, you had a successful push in the legislature to remove existing restrictions to late-term abortions. In Virginia, you had a unsuccessful effort to do largely the same thing. But it’s the Virginia bill that was ultimately unsuccessful that really sort of spurred a lot of interest in this when you had the governor of Virginia, Ralph Northam – he made some comments that were interpreted by a lot of conservatives to be what they considered a de facto description of infanticide. And that drove a lot of interest in this.
KELLY: All right. We saw President Trump taking it up in the State of the Union address, for example.
DEBONIS: That’s right. He referred directly to Governor Northam in what he said.
KELLY: The fact that this came to a vote in the Senate at all – Senate Majority Leader Mitch McConnell is famous for not letting bills come to the floor that he doesn’t want to come to the floor. What can you tell us about why he allowed this one to do so?
DEBONIS: Well, I think it’s pretty simple that he sees a political moment here in an issue that is uniting Republicans and dividing Democrats. You did see an uproar among conservatives after Governor Northam made his comments, and you did see some divisions in the Democratic ranks. You had three Democrats, including Doug Jones, who will be up for re-election next year, voting for it. So in Mitch McConnell’s mind, that’s a no-brainer. If it keeps your people united and divides your opponents, you should go ahead and put it up for a vote.
KELLY: Thank you, Mike.
DEBONIS: Thank you.
KELLY: He covers Congress for The Washington Post.
Copyright © 2019 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.
NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.
New Mexico Eyes A 'Medicaid Buy-In' Plan To Insure More Residents
Leah Steimel (center) says she would consider buying insurance through a Medicaid-style plan that the New Mexico Legislature is considering. Her family includes (from left) her husband, Wellington Guzman; their daughter, Amelia; and sons Daniel and Jonathan.
Courtesy of Leah Steimel
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Courtesy of Leah Steimel
Laura Lucero Y Ruiz De Gutierrez has a heart condition and fibromyalgia and is at high risk of developing diabetes. She has health insurance through her husband’s job. But between the $800 monthly premium for the couple’s coverage and the $2,100 deductible she has to pay down before insurance starts picking up the tab, she doesn’t feel she can afford to go to the doctor when she needs to.
She hopes that this may soon change. Identical bills proposed in recent weeks in the New Mexico House and Senate would make Gutierrez eligible to buy into a public health plan modeled on the Medicaid program, with funding support from the state of New Mexico. She could receive state-funded assistance via the program that would save her hundreds of dollars a month on premiums.
Laura Lucero Y Ruiz De Gutierrez has health insurance but says she still can’t afford to go to the doctor when she’s sick. She hopes the public health plan New Mexico is considering will change that.
Courtesy of Laura Lucero Y Ruiz De Gutierrez
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Courtesy of Laura Lucero Y Ruiz De Gutierrez
“Medicare for all” – often described as a national, single-payer health system built on the Medicare model — has become a rallying cry for some progressive Democrats. Meanwhile, New Mexico is one of several states looking at offering consumers a different type of government-sponsored plan to provide a health care option that’s more affordable than current options.
These states’ proposals are often referred to as “Medicaid buy-in” plans because, typically, they would offer benefits similar to what is available through Medicaid, the state-federal health plan for people who have low incomes.
The proposals under consideration vary from state to state. Variables include eligibility criteria, how they might be funded and whether they would be offered on the Affordable Care Act’s insurance exchange.
And depending on how they structure their plan, states may have to get approval from the federal government to move ahead.
States that are interested in a buy-in plan typically are considering taking advantage of the Medicaid program’s provider networks and reimbursement rates. Those payment rates generally are lower than for Medicare and for commercial plans.
That may help keep costs down, though in some states it also means the network of doctors would likely not be as large as that found with Medicare or some commercial plans.
“Medicare-for-all is not going to happen legislatively in the next couple years,” says Heather Howard, who directs Princeton University’s State Health and Value Strategies program and is working closely with some of the states. “In the meantime, states are saying, ‘What about “Medicaid-for-more”?’ “
In New Mexico, the buy-in plan would be similar to the state’s Medicaid program. It would be offered outside the exchange and would not require federal approval to implement. The state would provide financial assistance to help people with lower incomes buy into it.
A report commissioned by New Mexico projected that up to 16,000 people would enroll in a program like the one originally proposed in the state’s bills and that their premiums would be 15 to 28 percent lower than plans sold on the individual market.
New Mexico Gov. Michelle Lujan Grisham favors a Medicaid buy-in option. She doesn’t have a position on the current bill, but she is following it closely, says Nora Sackett, the governor’s deputy press secretary.
In addition to the governor’s and lawmakers’ interest, other stakeholders have been deeply involved, increasing the odds of success, Howard says.
Lawmakers in Colorado, Oregon, Washington and Minnesota are among others exploring similar options, says Howard. Nevada lawmakers passed a bill last year that would have set up a Medicaid buy-in plan, but the Republican governor vetoed it.
“The proposals take on different flavors depending on the state” and what officials are trying to accomplish, she says, whether it’s increasing the number of people with insurance, making coverage more affordable or helping states avoid having “bare” counties where no marketplace plans are offered.
New Mexico’s bill would target individuals who aren’t eligible for Medicaid or Medicare and those who can’t get the Affordable Care Act’s premium subsidies because their incomes are above 400 percent of the federal poverty level (about $50,000 for one person or $103,000 for a family of four). The plan would also be available to state residents whose immigration status in the U.S. is undocumented.
And the measure would help people like Gutierrez who are vulnerable to the ACA’s so-called family glitch. Her husband’s $100 monthly premium for single coverage through his employer plan is considered affordable under the law because it costs less than 9.86 percent of their family’s income of about $46,000 a year. That makes her ineligible for premium subsidies on the exchange, even though the $800 premium for the two of them through her husband’s employer plan far exceeds that affordability percentage. Their three children already have Medicaid coverage.
“Right now, I pay to have the health care, but I can’t afford to use it,” says Gutierrez.
The bill would provide financial assistance from the state, with premiums and cost sharing for people whose incomes are less than 200 percent of the federal poverty level, or $60,340 for a family of five. The new coverage would take effect by January 2021.
Gutierrez, whose family lives in Albuquerque, would be eligible for financial assistance to help her buy into the Medicaid-like plan, while her husband stays on his employer plan. Because their $46,000 annual income is just above 150 percent of the federal poverty level, her monthly premium would likely be about $160 per month for a comprehensive plan with a $150 deductible, according to estimates by Manatt Health, which did the original state analyses of buy-in options that were published before the bills were introduced in January.
New Mexico has high levels of poverty, and 40 percent of New Mexico residents are already enrolled in the state’s Medicaid program, compared with about 23 percent nationwide.
“It’s the cornerstone” of our health care system, says Colin Baillio, director of policy and communication at Health Action New Mexico, an advocacy group. The legislation would use “those levers that Medicaid has to provide comprehensive coverage and a comprehensive provider network.”
The bills were passed by two legislative committees this month, with instructions for further study to examine expanding the buy-in plan to more groups. They now move to two other legislative committees for consideration, Baillio says.
And though hospitals and other health care providers would be reimbursed at Medicaid rates — typically lower than those for commercial plans — to the extent that people who are uninsured enroll in the new plan, some providers say they stand to gain financially.
“We’re obviously very supportive of anything that expands coverage,” says Jeff Dye, president of the New Mexico Hospital Association. “It’s the issue of getting some payment versus no payment for services rendered.”
If the Medicaid buy-in bill passes, Blanca and her husband, Hugo, could have health insurance for the first time since they moved to New Mexico 14 years ago. The couple and their oldest son, now 18, are undocumented immigrants from Mexico. (NPR is not using their last names, to protect the family’s privacy.) Their two younger children, who were born in the United States, are enrolled in Medicaid.
Hugo works as a plumber, and Blanca is studying early childhood development at a community college near their home in Albuquerque. Because they are unauthorized immigrants, they’re not permitted to buy health insurance on the ACA exchanges, even if they’re willing to pay the full price.
So like many people without insurance, they wait until they’re really sick before seeking help. When Blanca developed pneumonia a few years ago, the waiting lists for an appointment at community clinics that would see her without insurance were long. Finally, when she could no longer breathe comfortably, she went to the emergency department.
“It would bring us peace of mind not having to worry about our health care situation,” Blanca says through an interpreter.
Providing health care for residents who lack proper immigration status is “an underlying issue with many states that are considering a Medicaid buy-in,” said Chiquita Brooks-LaSure, managing director at Manatt Health, who co-authored the reports evaluating Medicaid buy-in options for New Mexico.
The New Mexico bill also would provide some relief for Leah Steimel’s family. Neither she nor her husband has employer-sponsored coverage, and with a family income of about $100,000, they don’t qualify for tax credits that would reduce their ACA premiums. They now pay more than $1,900 per month for a silver-level plan with a $10,000 deductible to cover themselves and two of their kids (the third is older than 26).
Buying into a Medicaid-like plan would be tempting, says Steimel, who works as a community health consultant with some of the groups advocating for the buy-in. Sure, she says, she does wonder if the Medicaid plan would be as easy to use as a regular commercial plan and if it would give the family access to as many providers.
“But being able to pay into something that would reduce by even a third what I’m paying now — I’d love that,” she says.
Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation and is not affiliated with Kaiser Permanente. Michelle Andrews is on Twitter: @mandrews110.
Planned Parenthood President Leana Wen On Trump Administration Title X Changes
NPR’s Lulu Garcia-Navarro talks with Leana Wen, a physician and the president of Planned Parenthood, about how a rule change from the Trump administration on Title X will affect her organization.
LULU GARCIA-NAVARRO, HOST:
Planned Parenthood, long the target of social conservatives, could lose a significant portion of its funding under a new Trump administration rule released on Friday. The rule will cut federal funding from organizations that make referrals for abortions or provide the procedure. This is a win for anti-abortion activists who pressured lawmakers to defund organizations with ties to abortion.
But critics say it will hurt lower-income women who depend upon family planning centers that receive what are known as Title X funds. Leana Wen is a physician and the president of Planned Parenthood, and she joins us now.
Welcome to WEEKEND EDITION.
LEANA WEN: Thank you, Lulu – good to be with you.
GARCIA-NAVARRO: You call these changes to the Title X program a gag rule. Explain.
WEN: This is a gag rule because what President Trump is doing is to put a gag on doctors like me to prevent us from providing our patients with full and accurate medical information. So if you are a woman who goes to a health center that receives public funding, you cannot be referred to abortion care, even if your life depends on it. This gag rule is unethical and unconscionable.
I mean, imagine if the Trump administration issued a rule that forbid doctors from telling our patients about their options for any other aspect of health care. It’s a direct interference with the practice of medicine and with our ethical obligation to our patients. And this is why over 100 medical and public health organizations oppose the gag rule, including the American Medical Association, the American Nurses Association and the American College of Obstetricians and Gynecologists.
GARCIA-NAVARRO: I’ve read that you won’t accept funds under the new rules.
WEN: Planned Parenthood will never force our doctors and nurses to compromise their ethics. We will never let politicians censor our health care providers and erode the trust that our patients have placed in us, which is to provide them with compassionate, judgment-free and comprehensive care. That’s our promise to our patients.
GARCIA-NAVARRO: But you could receive federal funds if you separated abortion services from family planning centers. The new rules say there needs to be clear physical and financial separation between government-funded services and abortion-related services.
WEN: This Title X gag rule isn’t about providing good medical care. It only does one thing, which is to restrict patients’ access to reproductive health care. It has no basis in medicine or science. And the only effect is going to be preventing 4 million Americans from receiving basic health care, including breast and cervical cancer screenings, affordable birth control and STI tests.
GARCIA-NAVARRO: Religiously affiliated groups are hoping to get the money instead. Conservatives say this provides good alternatives to women.
WEN: We should talk about what is evidence-based, science-based methods for ensuring that all people have access to the health care that they need. Title X is our nation’s program for affordable birth control and health care. And this program is intended to ensure that people with low incomes who live in rural areas or who don’t have health insurance still have access to cancer screenings and preventive care.
And I think it’s important to talk about the individuals who it will affect the most. It will disproportionately affect those who already face the greatest barriers to care. It’s women of color and families of low income. And we need to talk about the discrimination involved here because if you are wealthy and you have private insurance, you can still get the best medical care.
GARCIA-NAVARRO: But religious groups say they could provide those alternatives, that they feel like they too deserve these funds so that there isn’t a monopoly on care.
WEN: Look. I’m a doctor and a scientist. And I need to do what’s best for my patients based on medicine and science. And what we have done for nearly 50 years through Title X is to follow the best available medicine and science. Title X is recognized to be one of the most successful public health programs in reducing sexually transmitted infections and reducing unintended pregnancies. This is what works.
GARCIA-NAVARRO: Leana Wen is the president of Planned Parenthood. Thank you very much.
WEN: Thanks so much, Lulu. And thank you for your time.
Copyright © 2019 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.
NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.
Big Pharma Heads To Capitol Hill
The heads of the largest pharmaceutical companies will defend their pricing before the Senate next week. STAT reporter Nicholas Florko tells NPR’s Scott Simon that this will be a televised crucible.
SCOTT SIMON, HOST:
Criticism of America’s major drug companies is one of the few areas of bipartisan agreement of the U.S. Congress. Lawmakers in both parties profess to be outraged about price increases for life-saving drugs and treatments. Next Tuesday, the executives of some of the largest pharmaceutical companies in the country will go before the Senate Finance Committee. It’s expected to be a rough day for them. Nicholas Florko is the Washington correspondent for STAT, a news organization that covers health and the life sciences. He joins us in our studios. Thanks so much for being with us.
NICHOLAS FLORKO: Thanks for having me.
SIMON: Is it a little surprising they even agreed to come in?
FLORKO: Well, they really didn’t have a choice, quite frankly. If a congressional hearing – congressional committee wants to hear from you, either you come in voluntarily, or they can issue you a subpoena. And, frankly, they’re a lot nicer when you come in voluntarily.
SIMON: Can we assume the PR firms that are of counsel to all these major corporations have been working overtime to try and help them?
FLORKO: Yes, absolutely – not only PR firms but probably law firms that specialize in this as well.
SIMON: What kind of reception do you think they’re going to get?
FLORKO: It’s probably not likely that they’re going to get a friendly reception. I mean, these hearings are just as much about getting information from the drug companies as it is an opportunity for the lawmakers to make a public stand about this issue.
SIMON: I imagine no legislator thinks he or she will look very good if they say, by the way, I think price increases are great. Thank you.
FLORKO: Exactly. They realize that they are going to be on TV, the nightly news. And they want to make a point about this issue to their constituents.
SIMON: Tell us about some of the figures we’re going to be seeing – for example, Richard Gonzalez.
FLORKO: Yeah. They’re a really interesting group. So Richard Gonzalez is the CEO of the company AbbVie. Interesting company because they are not a household name, but they make a drug that’s a household name, which is Humira. You’ve probably seen the TV ads for them.
SIMON: An expensive household name.
FLORKO: Very expensive household name and on pace to be the most lucrative drug in pharmaceutical history. He is a college dropout. But he has worked his way up to CEO at AbbVie. But he’s going to face some really tough questions about these strategies the company’s used to protect this drug for so long from competition that would lower the price.
SIMON: The producer of the top-selling insulin in this country is Sanofi. I hope I’m pronouncing that correctly.
FLORKO: Yes.
SIMON: And Olivier Brandicourt.
FLORKO: That’s correct. So I call him the heel of the group because he is the one who’s going to probably face some of the toughest questions. There is bipartisan anger over the issue of insulin prices. And he is sort of No. 1 target for asking questions about why the price of insulin is so high.
SIMON: It’s essentially quadrupled for a lot of people, right?
FLORKO: That’s correct.
SIMON: Pascal Soriot of AstraZeneca.
FLORKO: So he’s my favorite of the group. My guess is if you’re going to have somebody who’s going to have a slightly embarrassing soundbite on the nightly news, it might be him. He’s kind of known for being the outspoken one, grew up in the suburbs of Paris, has talked a lot about how he used to be in fistfights as a kid. He’s actually groused to the media about how he’s the lowest paid CEO in the group, even though he makes over $12 million a year. It’s going to be interesting to see how he handles the questions that he gets.
SIMON: Whatever speeches lawmakers are going to deliver, is it a little too simplistic to hold the pharmaceutical companies responsible in and of themselves for drug prices? Because, of course, there’s a third-party payment system.
FLORKO: Yeah. I mean, it’s a super complicated area – no doubt that’s going to be the line that a lot of these companies use is you have to look at others in the supply chain. But my guess is that – obviously, the members of Congress want to hear from the drugmakers. But my guess is they want to hear from others, too. So I’d stay tuned in that round to see if there’s other hearings where we might hear from others in the supply chain.
SIMON: Pharmaceutical companies, I imagine, will also argue that you have to have, let’s say, an increasing price for insulin so they have the money to develop whatever eventually replaces insulin.
FLORKO: Of course. The issue with that argument, though – somebody like Richard Gonzalez is going to have some trouble with that because that’s a drug – his drug Humira as a reminder – that drug has been – was supposed to be eligible for generic competition a long time ago. And they’ve been accused of essentially gaming the system to keep their protection longer and longer. So the argument from lawmakers is you had your time to recoup your investment. Now it’s time to let cheaper drugs come on the market.
SIMON: Do your reportorial instincts tell you the hearing will be fair and real in attempt to discover something or just an opportunity for politicians to get soundbites?
FLORKO: It’s a little bit of both, honestly. It’s definitely going to be a show. I mean, we’ve looked at the hearings that have happened previously. You know, you had the Martin Shkreli pharma bro hearing a few years ago. And you had the EpiPen hearing about the price of that drug. There’s definitely going to be a fair bit of just grandstanding and opportunities to slam drug companies. But between the lines, these lawmakers are interested in figuring out how to legislate here. So there’ll be some interesting questions, too, that can inform legislation.
SIMON: Nicholas Florko, reporter for STAT news, thanks so much for being with us.
FLORKO: Thank you so much for having me.
Copyright © 2019 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.
NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.
