Okay to allow insurance companies to require drug switch.

Today, 3/30/23, the Des Moines Register published an opinion essay by Lynn Rankin. She advocated for a proposed law to restrict insurance companies from requiring patients taking high-cost drugs to try switching to lower-cost drugs that are considered therapeutically equivalent.

 It is very reasonable for both private and government-sponsored healthcare plans to require you to try a lower-cost drug that meets your needs before going to a higher-cost drug.  If you start on a high-cost medication, it seems reasonable to ask you to try a lower-cost drug that has been determined to be therapeutically equivalent.  If you and your doctor don’t want to try a lower-cost drug first, it again is very reasonable to require a prior authorization request that shows evidence why the lower-cost drug should not be tried first. It is also reasonable to charge higher co-pays for higher-cost drugs as an incentive to encourage the use lower cost alternatives.

 It is very easy for doctors to prescribe the newest and most costly drug to treat any illness, especially since patients typically pay out of pocket only very a very small portion of the total cost of the drugs they take.  That is part of the reason why our health insurance costs are so high. If people had to pay the full amount for the drugs they take, they would look for lower cost alternatives on their own.

Non-medical switching of prescriptions may be appropriate.

The Des Moines Register recently published an essay by retired pharmacist and former state senator, Tom Greene, in which he supported proposed legislation that would prohibit insurance companies from switching patients to lower cost drugs or increasing co-pays if the patient is stable on a currently prescribed medication.  (“Protect health and end non-medical switching” 2/14/2022) (Link below.)

So, if the newest highest-cost drug works for a patient, this bill would make it illegal to try to change that patient to a less costly drug.  If that’s true, then maybe the law should also require that the lowest-cost drug in the same therapeutic class be tried first. 

If people had to pay their own way for prescription drugs, many would try lower-cost drugs even if a higher-cost drug was working effectively for them.  It seems fair to allow insurance companies to try to save money.  It also seems fair to require higher co-pays if a higher-cost drug is chosen.  If the proposed bill is passed into law, it will certainly help to push prescription drug insurance premiums higher and higher.

Link to essay in The Des Moines Register: https://www.desmoinesregister.com/story/opinion/columnists/iowa-view/2022/02/14/end-non-medical-switching-and-protect-iowans-health/6726589001/

Some drug price control by Government/Medicare is probably appropriate.

Jessica Hyland is correct that if our government starts regulating drug prices, then the development of new drugs will slow down. (Below is the link to her essay in the Des Moines Register.) Our current government policies have given us more new drugs at higher prices than we are willing to pay for. So maybe getting new drugs more slowly would be a good trade-off for significantly lower drug prices.

Good health might be the most important thing in our lives, but it is not the only thing. The pandemic proved that many people are willing to risk their health in order to do those other things they consider to be important in their lives.

Today, drugs approved by the FDA are required to be covered by Medicare regardless of the price, and whether or not the drug is any better than cheaper existing drugs!  Government granted patents prohibit competition by generic drug makers for 20 years or more!  There is clearly no free market for prescription drugs.  As a libertarian, I would love to see our government get out of the healthcare business altogether, but we don’t live in that world.  Our government has had its thumb on the scales in favor of drug companies for decades, so it is not unreasonable for it to now start regulating drug prices.

Link to Register essay by Jessica Hyland: https://www.desmoinesregister.com/story/opinion/columnists/iowa-view/2021/05/25/hr-3-prescription-drugs-stifle-health-care-innovation/5240432001/

Our ability to pay for prescription drugs is not unlimited!

I agree with John Stanford’s essay in the Wall Street Journal today that controlling drug prices would slow biomedical innovation and and research.  (WSJ 7/2/2020 – see link below.)  When you spend less money on anything you will get less of it.  But that’s okay.  Today, we get more drug research and innovation than we want to pay for.

Most drugs approved by the FDA are required by law to be covered and  paid for by Medicare and Medicaid regardless of price! Many are required by law to be covered and paid for by private insurance companies regardless of the price!  This is true even when the drug provides little or no improvement over other existing approved drugs!  Under such a situation we, of course, get maximum research and development.

If we did the same for space exploration, we would probably already have colonies on Mars.  If we did the same for climate change, we would probably already have that problem solved.  The point is that development of new prescription drugs is not our only priority, and our ability to pay is not unlimited.

We don’t have anything close to free market capitalism in the prescription drug market in the U.S.  Government is already very involved, mostly providing subsidies, protection from competition, and other benefits to drug manufacturers.  It is not unreasonable to set a drug price ceiling that is 20% higher than what is being paid by Australia, Canada, France, Germany and Japan.  We can always make special exceptions for something like a vaccine against the Covid-19 virus.

Link to John Stanford essay in WSJ:

https://www.wsj.com/articles/price-controls-would-throttle-biomedical-innovation-11593625880?mod=searchresults&page=1&pos=1

Don’t add long-term care coverage under Medicare

Contrary to the Register Editorial on 12/1/2019, we should not add long-term care as a new benefit under Medicare.  (See link below to The Register’s Editorial urging Medicare coverage of long-term care.)  If we want to solve problems using the force of government, we should do the minimum needed to solve the problem.  In this case, the problem is making sure that people receive medically necessary long-term care, not making sure that money is left to people’s heirs.

We currently have a pretty good situation: Many people voluntarily purchase private long-term care insurance.  Many others who could afford insurance choose to take a risk and not buy it.  Taxpayer-funded Medicaid covers the cost of long-term care for those who are unable to pay.  For those in the middle – not on Medicaid, but who would struggle to pay for private long-term care insurance – Medicaid already goes a long way to help them qualify for long-term care coverage.   For example, if one spouse of a married couple needs long-term care, the other spouse gets to keep a house and a car and some income, even though Medicaid pays for the long-term care of the first spouse.

The best long-term, sustainable solutions to our problems is to give voluntary, free choice to people and then expect them to be responsible for their decisions.  To the extent that we allow our government to force everyone into one-size-fits-all welfare programs, there will be ongoing, unsustainable frustrations, disagreements, and dependency problems.

Link to Register Editorial:   https://www.desmoinesregister.com/story/opinion/editorials/2019/12/12/medicare-should-cover-long-term-care-services-buttigieg-editorial/2629628001/

We don’t need a new mandatory federal government entitlement program.

Our population is aging and we all want to stay in our own homes as long as possible.  We definitely do have an increasing demand for in-home caregivers.  But I urge our Presidential candidates and our elected federal representatives to not support the mandatory Universal Family Care proposal as described  by Al-jen Poo in her recently published essay.  (See link below to the “Your Turn” essay by Al-jen Poo published in The Des Moines Register on 9/19/2109)

We do not need, and should not create, a new federal government sponsored, taxpayer funded entitlement program!   Such a scheme would make us even more dependent on our government.  Caregiving for family members at home should be left to family, friends and voluntary charitable efforts. This is part of being a family and accepting responsibility for ourselves and our loved ones.  Yes it is a burden, but it is one that we should accept.

LInk to Register “Your Turn” essay:

https://www.desmoinesregister.com/story/opinion/columnists/caucus/2019/09/16/ask-2020-candidates-support-universal-family-care-loved-ones/2345355001/

 

Trump administration and CMS capitulate to Big Pharma on efforts to reduce Medicare Part D drug costs

Recently, Gloria Mazza wrote, (and other Iowa Republicans signed), an essay in The Des Moines Register that urged President Trump and Iowa’s Republican Senators to oppose recent proposals by the Centers for Medicare and Medicaid Serivces (CMS) that would have taken reasonable steps to reign in increasing drug cost under Medicare Part D.  It has now been reported that CMS and the Trump administration have backed off of important parts of the proposed changes.

Currently, Medicare Part D regulations require patient access to “all or substantially all” medications within “six protected classes” of drugs regardless of price. (Protected classes include drugs for HIV, mental illness, cancer, epilepsy, and organ transplants.)

Among other things, the proposed new rule would have allowed Medicare Part D plans to exclude a drug from coverage, 1) for an existing drug if the price increased more than the rate of inflation, or 2) for a new drug if it was simply a reformulation of an existing drug.  Apparently, lobbying efforts were successful in getting these two provisions removed from the final new rule.

We don’t have a free market for prescription drugs under Medicare Part D.  We should not allow drug makers to set their own price and still require coverage.  It is unfortunate that the Trump administration caved-in to the lobbying pressure.

Link to Register essay by Gloria Mazza: https://www.desmoinesregister.com/story/opinion/columnists/2019/05/16/pro-life-advocates-dont-reduce-medicare-part-d-protection-drugs-congress-chuck-grassley-joni-ernst/3685349002/

Don’t require Medicaid or other health insurance plans to cover gender transition surgery.

The Iowa Legislature made the correct decision when they passed the bill that prohibited Medicaid from covering gender transition surgery.  One the one hand, it is morally correct and good public policy that our government not discriminate against a people based on their gender identity.  On the other hand, that does not mean Medicaid or any other insurance should be required by law to cover gender transition surgery.  Proponents of requiring such coverage say that it is medically necessary because of the mental distress that gender dysphoria may cause.  But, cosmetic surgery of any type has not been required to be covered just because a person feels bad about the way they look physically.

I’m sure some people feel great mental distress over their teeth being crooked, or their nose being too big, or many other aspects of their body, but that does not mean Medicaid (taxpayers) or other health insurance plans should be required to cover procedures to make people feel better about their appearance.  Requiring health insurance plans to cover almost everything makes the makes the cost unaffordable to almost everyone.  There is nothing inherently wrong with expecting people to pay their own way for cosmetic procedures.

Gender reassignment surgery should not be required to be covered by health insurance.

As reported in the Des Moines Register, a jury recently found the State of Iowa guilty of illegal discrimination against a transgender man.  He had not been allowed to use the men’s bathroom or locker room, and he had been denied health insurance coverage for gender re-assignment surgery.  (See link below to Register article.)

It is morally correct and good public policy that our government not discriminate against a people based on their gender identity.  But refusal by government or private employers to cover gender reassignment surgery under their health insurance plans should not be considered wrongful discrimination, unless the plans cover other types of cosmetic procedures for people who feel similar dysphoria.  People may feel mental distress over their teeth being crooked, or their nose being too big, or many other aspects of their body, but that does not mean health insurance plans should be required to cover procedures to make people feel better about their appearance.  We have already seen that requiring health insurance plans to cover almost everything makes the premiums unaffordable for many people.  There is nothing inherently wrong with expecting people to pay their own way for cosmetic procedures.

Link to Register article: https://www.desmoinesregister.com/story/news/local/columnists/courtney-crowder/2019/02/13/transgender-prison-nurse-sues-iowa-alleged-discrimination-aclu-state-civil-rights-corrections/2863854002/

How to slow the growth of health care costs.

Thanks to Susan Voss for her thoughtful essay about the complexities of our health care system, and how difficult it is to reduce costs. (See link to Register essay below.)   I don’t claim to have “the answer”, but I do suggest that the following cost saving ideas be given serious consideration.

• Medicare, Medicaid and private insurance should not be required to cover every new drug, product, or procedure that is approved by the FDA. Some are very high cost but provide only marginal improvement over alternatives that cost much less.  Also, at least some covered products and procedures would likely be considered not medically necessary by most people.
• Consider shortening the amount of time that government grants a monopoly for patents.  Patents are not natural property: humans have copied one another since the beginning of time.  Our U.S. Constitution allows patents to be granted to encourage inventiveness, but there is no objective reason why a patent must be granted for 20 years. Why won’t five or ten years work?  Maybe the length of the patent should be based on the cost to develop the patented item and whether or not government funds were used to help develop the item.
• Don’t require limits on out-of-pocket payments such as co-payments, especially for very high cost items.  A person should have “skin-in-the-game” if they expect their insurance to cover very high cost items.  Today, we see the opposite: drug companies offer to help pay people’s out-of-pocket costs so there won’t be so much political pressure on them to lower their prices.
• Allow both pharmacies and individuals to purchase drugs from sellers in other countries that are “deemed” to have sufficient safety procedures in place.  If drug companies are free to charge lower prices in other countries, then pharmacies and individuals should be free to purchase the drugs from those other countries.
• Allow Medicare and Medicaid to negotiate with drug companies on prices they pay for the drugs that are covered by the programs.  Right along with that, Medicare and Medicaid should be allowed to develop formularies (lists of drugs that are preferred over other therapeutically similar drugs), that give beneficiaries a financial incentive to use the preferred drugs and a penalty for using higher cost drugs.

Our health care wants are unlimited.  Our ability to pay is not.  We, as citizens, should not expect private insurance or our government health care programs to cover everything, regardless of cost.  We should expect our government to NOT do things that increase costs, or reduce our choices.

Link to Register essay:  https://www.desmoinesregister.com/story/opinion/columnists/iowa-view/2018/09/19/dont-fooled-when-someone-claims-have-answer-soaring-health-care-costs/1355890002/