Here’s the most underrated part of the Democrats’ prescription drug bill


Lisa McCripley has been living in multiple sclerosis more than ten years. Although the condition eventually forced her to leave her job and move from California to Michigan to be with her family, she remained active — volunteering with MS advocacy groups, attending church events — and slowing the disease’s progression with the help of medication. Progress and reduce the severity of symptoms.

But treatment is expensive, and McCripley’s Medicare-paid drug bills cost her hundreds of dollars, sometimes more than a thousand, out-of-pocket for prescriptions at the pharmacy. McRipley told The Huffington Post in an interview with The Huffington Post that making regular income payments is a real struggle, but not taking medication is not an option because she found the hard way this summer, At the time she temporarily stopped taking some pills for a week and began to lose mobility, dexterity and balance.

“I’ve even lost the ability to eat with a fork or spoon — it’s like day and night,” McCripley said.

McRipley is back on medication, but, as is the case with relapsing and remitting MS, she fears she will never get back to where she was. While McRipley couldn’t be sure that discontinuation was the reason her condition worsened, she was sure how the cost of her medication would affect her life even if she was able to take it.

“It was really frustrating because I had to ask for help, like groceries,” McCripley said. “I’m asking my parents…I should be in a position to help them now, not the other way around.”

McCripple’s story is anything but unusual or limited to suffering from multiple sclerosisHigh costs also appear to discourage Medicare beneficiaries with cancer, hepatitis C and certain immune diseases from taking the drug, according to a major paper published in the journal. health affairs earlier this year.This is not the first study document this effect.

Democrats have been promising to help people like McCripley, and they may be about to deliver on that promise by passing the Lower Inflation Act, which leaders hope to pass and submit to Joe Bye in the next few days. signed by the President.The legislation includes several items aimed at reducing What people pay at the pharmacy counter. The most well-known and most controversial These would give the federal government the power to negotiate the prices of drugs covered by Medicare, something governments in other economically developed countries are already doing, and a big reason why drug prices are rising in these countries much lower than they are here.

But only a limited number of drugs will be negotiated before 2026 in a process that won’t lead to a drop in the prices of those drugs. Even so, drug prices in the U.S. will likely remain much higher than in other countries, meaning Medicare beneficiaries like McCripple will still need more help, preferably sooner.

They might get it.This Other prescription drug reforms Pass hard limit superior out-of-pocket drug costsBeginning in 2024, it will be phased in over two years so that by 2025, beneficiaries like McRipley will pay no more than $2,000 a year for drugs that now cost them many times.

McCripley said the rule could be a “lifesaver” and if the research is correct, it is indeed true. But it all depends on the actual bill passed. At the time of writing, this is still uncertain.

Medicare beneficiaries have drug coverage—a big gap

The story of why Medicare beneficiaries owe so much prescription drugs dates back to 2003, when President George W. Bush signed the law This creates Medicare’s drug benefit, called Part D. The program meets a huge need. Before this time, Medicare beneficiaries often could not find drug coverage.

But the plan’s chief architects are Republicans and conservative Democrats who refuse to allow the federal government to influence drug prices or spend the money necessary to fund the kind of comprehensive benefits that many seniors need.Therefore, Part D has Huge gap in coverageleaving seniors exposed to large deductibles, copays, and coinsurance.

This Affordable Care ActSigned by President Obama in 2010, it partially addresses this problem by gradually closing a large gap in coverage – or Close the “Donut Hole”, well known.This Bipartisan Budget Act of 2018Signed by President Donald Trump, expediting the process.

“These [drugs] Not optional for people. These are all you need to prolong your life or prevent your condition from getting worse. “

– Stacie Dusetzina, Associate Professor, Vanderbilt University

But even if these reforms were fully in place, Medicare beneficiaries would still be responsible for a fraction of the cost of their drugs, with no limit on the total.

That portion is small, only 5% once drug spending reaches a certain threshold. But some drugs are priced so high — tens of thousands, even hundreds of thousands of dollars a year — that 5% becomes punitive enough to prevent patients from taking them entirely.

“I think there’s a perception that just because someone has Medicare, they’re covered, and they’re covered for most of their prescription drug costs and other types of expenses,” said Amy NilesDeputy Vice Director Pan Foundation, which provides financial assistance to those who cannot afford medical care. “But when it comes to prescription drugs, that’s not the case. So for people with Medicare … there’s no limit to how much you can out-of-pocket for these drugs.”

Sometimes people skip the medicine they need

This Research that appeared in Health Affairs earlier this year Shows the severity of the impact. The researchers found that nearly one-third of Medicare beneficiaries who were not eligible for additional government assistance failed to fill out new prescriptions.

“We know these are critical drugs, and many of them are recommended for first-line treatment,” Vanderbilt associate professor and lead author Stacey Dusezina told the Huffington Post. “So these are not optional for people. These are what you need to live longer or prevent the disease from getting worse. In fact, it’s almost a third, which is really exciting.”

Not all drugs that Medicare beneficiaries need translate into such high personal costs. Primarily the individual beneficiaries use their Part D coverage for drugs purchased directly at the pharmacy. The infusions and other drugs they get at doctors’ offices and clinics are usually covered by Medicare Part B, which pays for outpatient services, and Part B cost-sharing is usually much lower because most beneficiaries have supplemental coverage or pay out-of-pocket Expenses limit medical expenses.

Senate Majority Leader Chuck Schumer (D-N.Y.) speaks during a news conference on the Inflation Reduction Act Thursday outside the U.S. Capitol. The bill is expected to include a three-year subsidy for Affordable Care Act premiums and some prescription drug reforms.
Senate Majority Leader Chuck Schumer (D-N.Y.) speaks during a news conference on the Inflation Reduction Act Thursday outside the U.S. Capitol. The bill is expected to include a three-year subsidy for Affordable Care Act premiums and some prescription drug reforms.

Drew Angler/Getty Images

To illustrate the illogicality of this distinction, Dusetzina example of breast cancer.

A common type of treatment (called HER2-negative cancer) is a drug that people take by mouth. For Medicare beneficiaries, out-of-pocket costs can exceed $10,000 per year. The treatment for another variant, HER2-positive breast cancer, is an infusion, which will cost a fraction of that amount for most Medicare beneficiaries.

“That means you might feel lucky because you have a cancer that is treated with an infusion instead of a pill,” Dusetzina said. “It doesn’t make sense at all.”

Charities provide vital help, but it’s not enough

Joan Durnell Powell doesn’t need a study to tell her the high cost of the drug and the options it imposes on patients.Powell, a California retiree, was diagnosed with myelodysplastic syndrome, a type of blood disease. The drugs she took kept her alive, but the out-of-pocket costs were high in the four figures, often five figures, she said in the interview.

Like many Medicare beneficiaries, Powell has received help from several private charities, including the PAN Foundation, that help those who cannot afford medicines. “I really wouldn’t be able to live without the support of these foundations.” But Powell said that sometimes grants come due or paperwork doesn’t go through, and even if there is money, only part of the bill can be paid.

Today, she says, she still needs to put out about $5,000 to $6,000 a year — less than $30,000 a year on a regular basis. “Whenever I tell people about it, I say I don’t have to worry about my illness. I have to worry about my co-pays.”

Limitations on what charities can offer is the reason these organisations line up Affordable Medicines for Patients, American family and other health care advocacy groups support the proposed cap on out-of-pocket costs. They were also enthusiastic about some related provisions in the Democratic legislation, including a proposal to expand support for low-income Medicare beneficiaries.

Reform package has real trade-offs

Like all policy proposals, the Democratic legislation has some trade-offs, mostly new forms of government spending in the case of out-of-pocket cost caps and low-income aid.

In other words, Medicare beneficiaries like McCripley and Powell will soon pay less for their drugs under the Democrats’ proposal, as the federal government will directly shoulder more of the financial burden.

That helps explain why the two provisions are part of the same bill, which requires the government to negotiate drug prices. Negotiations of legislation and some related provisions will reduce Medicare spending because Medicare won’t have to pay as much for individual drugs as the price of them falls.

“I don’t have to worry about my illness. I have to worry about my co-pays.”

– Joan Durnell Powell, California Medicare beneficiary

The pharmaceutical industry and its allies, including Republicans and some Democrats, have warned that lowering drug prices will reduce profits for drug companies and make it harder for them to attract the investment capital they need to fund the development of new drugs.it could mean Fewer breakthrough drugslike the kind that is now used to treat McRipley’s MS and Powell’s blood disorders.

But analysts are Congressional Budget Office Zeng said they think the impact of the Democratic bill on innovation is likely to be small.while at the same time a large number of researchers think about the effect possibly biggerDusetzina is one of a large group of people who think the CBO is doing the right thing.

“I think the bill strikes a good balance — putting guardrails around which drugs are eligible for negotiation and starting with just a handful of drugs,” Dusetzina said. “So, I think, the pharmaceutical industry’s claim that there is no cure is overblown.”

Of course, if the Reducing Inflation Act doesn’t pass Congress, the proposal won’t have any impact on innovation or drug prices. While all 50 senators in the Democratic caucus now say they support the bill, clearing the way for it to pass, the pharmaceutical industry is pushing hard to break up the coalition.

A lot depends on the outcome. For some Medicare beneficiaries, it could even be a matter of life and death.





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