Column: Hot Air and Cheap Drugs

Fifty senators and the Vice-president voted to pass a bill that they claim will cut drug costs and reduce green-house gas emissions. The cuts in green-house gasses have been projected to occur over the next ten years, and the reduction in drug costs will theoretically materialize after the next Presidential election. We shall see. The Senators supporting the bill celebrated with all the enthusiasm of a kindergarten class that had finally won its first softball game. In fairness, we must recognize that these men and women had to abide by arcane rules and innovative maneuvers to accomplish what they have rarely accomplished in recent years, that being doing the job they were sent to Washington to do.

The spokespeople for the successful “caucus” described their accomplishment as an impossible dream come true, rather than as a good day at the office. Their comments and the disparaging remarks from the political team that opposed the bill indicate that the Senate has drifted far from the contemplative body of independent thinkers concerned only with the common interests of its citizens as envisioned by the authors of the Constitution. The Senate currently resembles a body composed of two teams, both of which are more focused on the other’s defeat than on ensuring a “more perfect union” or promoting “the general Welfare.”  

With the nonperformance of this legislative body in mind, one must be suspicious when they claim that they enacted one of the most consequential bills in recent history. The green-house gas emissions restriction will require an enormous bureaucracy to make it work. The bill that was passed seems to provide generously to get this initiative through its early years of life, but the fifty senators who voted against this commonsense, planet-saving directive can be expected to take every opportunity to emasculate or stifle it before it is up and running. The money allocated may not necessarily be spent. Like the Affordable Care Act, its provisions and vital elements (remember the Public Option) may be pruned away before they get implemented.

The war on carbon emissions may have already been lost, given the incompatible bargains made to get the bill passed. The Senator from West Virginia, a man who serves at the behest of the fossil fuel industries, demanded and got commitments to enable the construction of a massive natural gas pipeline in his state, a pipeline that has been opposed by many of his constituents and all of the courts that have reviewed their objections to this project. The Senators backing the bill agreed to relax the environmental impacts routinely demanded of a project like this pipeline, and shunted the hearings connected to planned construction to a more “sympathetic” court. The irony of facilitating a project that will greatly increase green-house gas emissions in a bill to reduce those emissions was apparently lost on the sponsors of the bill. We should know within a few years if the billions allocated for this initiative benefit anyone besides the West Virginia Senator and his friends in the coal, gas, and pipeline industries.

The other measure touted as a giant step forward for free enterprise is the measure that allows Health and Human Services (Medicare) to negotiate drug prices for Medicare recipients. This means that the government will determine what are reasonable prices for some of the drugs prescribed for people enrolled in the so-called Part D or Medicare Advantage plans. Until now, the thousands of insurance companies offering this drug coverage negotiated individually with dozens of drug companies. Medicare was not only banned from negotiations but was also banned from creating a formulary of covered drugs. These measures were taken to guarantee “competition” between plans. It did not work.

Each insurance company had to determine what drugs its plans would cover. If someone wanted to know what drugs he or she would have covered by their insurance plan and what manufacturer would be supplying those drugs, he or she would need to get listings from the insurer. Even with this listing in hand, the insured party often found that the fine print in their contracts included special provisions that shifted the cost of expensive drugs to the insured or highly restricted what new and expensive drugs could be prescribed without extra cost.

The theory behind the new rule is that the government, as a representative for all Medicare Plan D recipients, has much more negotiating leverage than individual insurance companies, regardless of how many people each of those insurance companies serve. The weakness in this is that many of the most expensive and highly prescribed drugs are only available from one manufacturer or one distributor.  A manufacturer or its designated distributor has no competitor during the life of the drug’s patent. It can charge whatever it wants, and the insurance company was told to take it or leave it. Insurance companies routinely dealt with this by simply omitting the costly drug from its formulary, its listing of covered drugs. The government may face the dilemma of being obliged to pay the demanded price if the Food and Drug Administration (FDA) has determined that the drug is safe and effective for the disease for which it is being prescribed. Only the most expensive and novel drugs will be subject to the government pricing review and, as currently written, the bill expects fewer than a dozen drugs to enter the convoluted negotiating process each year starting in 2026. Reasons to exclude drugs from the negotiating process are numerous and provide a variety of avenues for drug companies to completely avoid government imposed pricing.

Simply put, the original idea to increase competition by keeping the government away from the negotiating table failed. The prospects for reducing Medicare Part D drug prices with the government as the negotiator are slim unless the government institutes price controls, a measure that will trigger a major assault by the pharmaceutical industry lobby on congressmen and congresswomen who support such a measure. Unfortunately, with drug companies raising drug prices to levels that were unimaginable just a few decades ago, prices that are unjustifiable and capricious, there is little reason to believe that tweaking Medicare Part D will have any impact without laws mandating price controls.

There is much that Congress could do to reduce green-house gasses and drug prices. They apparently recognize the people’s desire for action. They took a baby-step in response to this increasing clamor for action, but the measures they barely managed to pass will more likely than not have little, if any, impact on their constituents and the planet. We deserve better from our Esteemed Colleagues.  

Dr. Lechtenberg is an Easton resident who graduated from Tufts University and Tufts Medical School in Massachusetts and subsequently trained at The Mount Sinai Hospital and Columbia-Presbyterian Medical Center in Manhattan.  He worked as a neurologist at several New York Hospitals, including Kings County and The Long Island College Hospital, while maintaining a private practice, teaching at SUNY Downstate Medical School, and publishing 15 books on a variety of medical topics. He worked in drug development in the USA, as well as in England, Germany, and France.

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