Libertarian Perspectives

A Blog By Kurt Johnson

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/

How to reduce U.S. overdose deaths.

It has been widely reported that more than 100,000 Americans died of drug overdoses during the 12 months ended April 30, 2021, a record high. A large and increasing portion of overdose deaths is attributable to illicitly obtained drugs, especially fentanyl. Many addicts have no choice but to buy their drugs on the black market, so they can’t be assured of the strength or purity of the drug, or what other drugs might have been added to what they think they are buying. As a result, many overdose deaths are accidental.

Imagine if we treated drug addiction using a medical model rather than a criminal model? If addictive drugs could be purchased legally and were regulated as to strength and purity, many overdose deaths would be avoided. Additionally, people who become addicted might be more likely to ask for help to kick the habit if they weren’t afraid of getting arrested and put in jail. Finally, much of the crime and violence associated with the illegal drug trade would go away if our policy of prohibition were ended.

As I’ve written before, if a new pharmacy opens in your neighborhood, the existing pharmacies don’t start a shooting war to protect their turf. And if someone breaks into or otherwise trys to rob a pharmacy, the pharmacy calls the police. It is the prohibition that causes most of the violence.

Under a legal drug regime, it would still be illegal to drive a vehicle while under the influence of intoxicants, and children would be prohibited from buying drugs. But a person who minds their own business would not be a criminal for using drugs in a peaceful manner.

Bootleggers and Baptists – strange bedfellows.

During the time of alcohol prohibition, bootleggers and baptists were both opposed to repeal of the Eighteenth Amendment.  It’s an example of how, “politics makes strange bedfellows.”  Even though the two groups seemed to have completely opposite views about drinking alcohol, they both opposed the repeal of prohibition: The baptists for moral reasons, the bootleggers for financial reasons.
I read the report in The Des Moines Register about how scared the Iowa medical marijuana dispensaries are about losing money once the legalization of recreational marijuana in Illinois begins next January 1st.  (see link below)  It makes me wonder if Iowa might face a similar situation in the future. The governor and many other politicians oppose efforts to legalize the recreational use of marijuana for moral reasons.  I wonder if Iowa’s legal medical marijuana producers and sellers will oppose efforts to legalize recreational marijuana for financial reasons?

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/

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/

 

Transgendered okay in the military, but sex change surgery should not be paid for by taxpayers.

A transgendered person should be eligible to serve in the military, just like just like every other man or women, and just like every other gay or straight person.  If they are qualified to do the job, then government should not discriminate against them based on their transgendered status.  That does not mean the military or taxpayers should foot the bill for sex change operations.  Just as being transgendered is not a disease, surgery to to change a person’s sex is not a medical necessity.  Transgendered folks will can be completely healthy without a sex change operation.  So, sex change operations should be considered elective, and not be required to be covered by any insurance plan, including that of the military.

EpiPens and Government Cheese – article from Reason Magazine

The November issue of Reason magazine included the article below by Katherine Mangu-Ward.  I think it is an excellent example of how our government can screw things ups, no matter how good the intentions.

 

EpiPens and Government Cheese

Some things won’t change no matter who wins the 2016 election.

At the end of August, the U.S. Department of Agriculture bought 11 million pounds of cheese—that’s a cheese cube for every man, woman, and child in America—in order to bail out the nation’s feckless cheesemongers.

Secretary of Agriculture Tom Vilsack touted the aid package, worth $20 million, as a win-win: “This commodity purchase is part of a robust, comprehensive safety net that will help reduce a cheese surplus that is at a 30-year high while, at the same time, moving a high-protein food to the tables of those most in need.” (Most of the federal government’s new stockpile will go to food banks.)

This bailout of Big Cheese came on top of an $11.2 million infusion earlier in the month to dairy farmers enrolled in a 2014 federal financial aid scheme. The deal comes after months of lobbying by the National Farmers Union, the American Farm Bureau, and the National Milk Producers Federation, who were too antsy to wait for their next big cash cow to come ambling in with the farm bill.

The same week, Sen. Chuck Grassley (R–Iowa) wrote a letter to the pharmaceutical company Mylan, demanding an explanation for why EpiPens, the epinephrine auto-injectors that severely allergic people carry in case of an emergency, have quadrupled in price since 2007. Grassley cited constituents paying $500 to fill their prescriptions.

Hillary Clinton issued a statement about the price increases as well: “Since there is no apparent justification in this case, I am calling on Mylan to immediately reduce the price of EpiPens.” Donald Trump used the occasion to score points, tweeting out a story about hundreds of thousands of dollars in donations to the Clinton Foundation from the disgraced company. Sen. Amy Klobuchar (D–Minn.) echoed Clinton’s sentiment in a letter to the Federal Trade Commission: Lamenting that “antitrust laws do not prohibit price gouging,” she asked the regulatory body to look into whether Mylan has used “unreasonable restraints of trade” to keep prices high.

The summer’s cheese bailout and EpiPen price scandal are ideological Rorschach blots.Where one observer sees only the evils of the profit motive, another looks at the same fact pattern and sees the perils of an overweening regulatory state.

Vox sided solidly with the profit shamers, declaring: “We are the only developed nation that lets drugmakers set their own prices, maximizing profits the same way sellers of chairs, mugs, shoes, or any other manufactured goods would.” But pseudonymous blogger Scott Alexander of Slate Star Codex responded with a tidy reverse Voxsplanation: The cronyist Food and Drug Administration (FDA) and other government forces have squelched nearly every effort to compete with Mylan’s EpiPens, distorting the market beyond recognition via a process he chronicles in painful detail.

Mylan acquired the EpiPen from Merck in 2007, by which time the product was already 25 years old, which means the question of paying back research costs was moot. In 2009, Teva Pharmaceuticals tried to enter the market—and Mylan sued. Teva managed to get its product to the FDA anyway, only to be told that it had “certain major deficiencies,” unspecified. In 2010, Sandoz Inc. tried its luck and got bogged down in the courts, where the case still dwells. In 2011, the French drug company Sanofi made a bid to gain approval for a generic, which was delayed for years because the FDA didn’t like the proposed brand name. Which brings us to this year, when Adamis decided to sell plain old pre-filled epinephrine syringes directly to patients without the fancy injector. Cue an FDA recall, on the rather vague basis that insufficient study had been done on standard administration of a drug whose medical properties have been known since the turn of the last century.

And sometimes the tangled, dysfunctional relationship between big business and big government gets even more personal. The CEO of Mylan, Heather Bresch, is the daughter of U.S. Sen. Joe Manchin (D–W. Va.), which probably makes things awkward in the Senate cafeteria. But Manchin has joined his colleagues in saying that he is “concerned about the high prices of prescription drugs,” which probably makes things awkward at Thanksgiving. Then again, Mylan spends over a million dollars a year lobbying, which likely goes a long way toward smoothing things over.

In 2014 Congress passed the School Access to Emergency Epinephrine Act, which Grassley mentions in his letter. The law, he writes, “provides an incentive to states to boost the stockpile of epinephrine at schools.” It was co-sponsored by Klobuchar, the same senator who now wants to sic the antitrust dogs on Mylan. That law was a top lobbying priority for Mylan that year, along with new rules that reduced competition for generics.

Grassley also notes that the taxpayers are picking up the tab for kids who are getting EpiPens while on Medicaid or the state-level Children’s Health Insurance Program, and he adds that some 47 states require or encourage schools and other public institutions to stock EpiPens. In other words, Congress created a huge new class of price-insensitive EpiPen customers and now wonders why the price has gone up.

Meanwhile, the prescription laws still require you to get a special piece of paper from a doctor every single time you want to buy an EpiPen. If the doctor writes a brand name on that paper, it’s illegal for the pharmacist to give you a cheaper generic.

The story of the government cheese is just as convoluted. It’s easy to be lulled by Vilsack’s sell: Helping farmers and the hungry? Sounds great! But you know what else helps move a glut of cheese off the shelves and into the hands of poor people, without requiring taxpayer dollars? Lowering the price.

That’s something the industry isn’t willing to do, and—given all the pricing rules and production quotas that have been distorting dairy markets since the 1930s—mostly can’t do. With Americans eating a record 34 pounds of cheese a year, the problem isn’t an unexpected drop in demand.The problem is a failure to allow the laws of supply and demand to function at all.

Eleven million pounds of cheese may seem like small potatoes (to mix culinary metaphors), and it is in the larger scheme of federal spending and meddling. What’s another $20 million when the debt is already $20 trillion, after all? But our typically cheerful acceptance of central control of compressed curds and injectable epinephrine shows how widespread and insidious such conditions are in our lives.

What would real free market reforms look like, and how would they come about? In this issue, you’ll read what Libertarian Party nominees Gary Johnson and Bill Weld would do in the (very unlikely) event that they won the presidency and vice presidency (page 30). Reason TV’s Jim Epstein reports on the millennial libertarian activists in Brazil who brought down a corrupt populist president (page 50). And in Detroit, an American city where public services are essentially nonexistent, we detail how residents are building DIY alternatives (page 65).

In the meantime, there is no reason to think either the tale of the EpiPens or the saga of the cheese would play out any differently under President Trump or President Clinton. Taxpayer-funded sops to farmers are as bipartisan as it gets, and there is precisely zero chance that a president from either major party would discontinue the practice. Likewise, the iron grip of the FDA on the drug approval process—and the opportunities to purchase influence in that powerful bureaucracy—will not diminish one iota, regardless of which major-party candidate becomes America’s Big Cheese in January.

EpiPen fiasco was caused by the FDA – don’t blame free market capitalism

Our government, not free market capitalism, is to blame for this situation which has allowed Mylan Pharmaceutical company to jack-up prices for its EpiPen. The FDA is has created a huge delay in approving generic epipens.  This has effectively given Mylan a monopoly.  Established drug companies should have some type of fast-track authority to manufacture generic products without having to get advance approval from the FDA.  Don’t blame private enterprise for problems created by government.

Lower prescription drug costs – the proper way.

The Register, in a recent editorial, advocated for letting people order their medications from other countries.  A bill introduced into Congress by Senator John McCain would allow people to legally buy their prescriptions from properly licensed Canadian pharmacies.  A better idea would be to allow U.S. prescription drug wholesalers and retail pharmacies to buy from Canadian manufacturers and wholesalers.  To only allow individuals to buy from Canadian pharmacies would be to pull the rug out from underneath U.S. pharmacies.  It would be simply unfair to allow individuals to purchase from Canadian pharmacies but not allow U.S. pharmacies to do the same.  The best answer is to allow free trade in prescription drugs at all levels.

 

Link to Register article:  http://www.desmoinesregister.com/story/opinion/editorials/2015/03/08/editorial-easy-way-lower-cost-medications/24629749/

Don’t force measles vaccine.

The question is not, “Is the measles vaccine is safe and effective?” (I presume that it is.)  The question is, “What are the limits of government power?”   A person should not be forced to inject something into their body against their will.  Period.  Everyone else can take steps to defend themselves.  Maybe not perfectly, but that is a price we pay for freedom.  Neither government nor any majority should be able to use force against those who are peaceful and honest, and who don’t use any force or fraud against others.