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/

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.

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

Patents should be more restricted, not liberalized.

I disagree with Paul Michel and Matthew Dowd, (Wall Street Journal, 1/24/2020, link below), that our patent laws do not give adequate and clear protection to inventions.  Conversely, we have become too liberal in both what is allowed to be patented and the length of time that patents are granted.

They urge the reversal by Congress of the Supreme Court of rulings that prohibit the granting of patents for “abstract ideas” and “natural phenomena”.  Abstract ideas, like mathematical formulas, computer code, or simple ideas drawn on paper, and natural phenomena, like the discovery of particular DNA or naturally occurring chemical compounds, should not be patentable.

Originally, U.S. patents had a maximum life of 14 years, then 17 years, and then 20 years.  Companies that earn billions of dollars in profits every year on their patents are very willing to spend many millions of dollars to lobby congress to extend their monopolies.  Who spends money lobbying to reduce the term of patents?  Shouldn’t the term of monopoly protection granted depend in part on how much it costs to meet government regulations related to the invention?  For example, prescription drugs may deserve a long patent term because of the cost to meet government regulations.  But there is no logical reason why all patents should be granted for the same length of time.  (Design patents are granted for shorter periods, but why should they be granted at all?)

The concept of “intellectual property” is man-made.  Since time immemorial, humans have copied one another.  For millennia legally protected private property was limited to physical property which could only be possessed by one person at a time.  Ideas can be possessed by many people at the same time without infringing on the physical property of others and without the use of force.  Monopolies, including the exclusive use of inventions, were originally granted by Kings to favored subjects through the use of force.  Our government protects patents through the use of force.  Contrary to the Founder’s intent, some patents appear to slow innovation rather than encourage it.  The case can be made that no patents should be granted.  In this case, Congress should expand patent protection.

Link to Wall Street Journal opinion:

https://www.wsj.com/articles/americas-innovators-need-clear-patent-laws-11579824646

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?

Link to Register report:   https://www.desmoinesregister.com/story/news/2019/07/09/marijuana-illinois-law-recreational-use-iowa-cannabis-department-of-public-safety-division-narcotics/1573867001/

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/

Big marijuana bust in Iowa – Mayor found growing pot!

As the Des Moines Register reported yesterday, the Mayor of Jamaica, Iowa and her husband were busted two days earlier at about 4:20 p.m. (no joke) for growing 18 marijuana plants inside their home.   The various related charges include a Class “D” Felony for the manufacture and possession with intent to deliver less than 50 kilograms of marijuana.

It’s a shame that our laws in Iowa still make it a crime to do something that is peaceful, voluntary, and uses no force or fraud against others. Marijuana prohibition laws do little to make our state safer, and yet do great harm to people who are victimized by them.  In this case, if these two people are found guilty of the felony, they could be sentenced for up to 5 years in prison, be required to pay up to $7,500, lose their voting rights, be disqualified for military service or student loans, and more.  Compare that to the fact that nothing happens to a person in her home who is found to be brewing 5 gallons of beer – a standard home-brew batch – and possessing, say, 10 to 20 more gallons that were brewed earlier.

Marijuana is no more dangerous than alcohol, and yet today we see the same unintended consequences resulting from drug prohibition that we saw from alcohol prohibition in the 1920s and early 1930s: violence, deaths from impure products, and the arrest and punishment of people who are otherwise honest and peaceful.  Make no mistake, the violence associated with the illegal drug trade is caused by prohibition laws.  If Walgreens moves into a community, CVS doesn’t send out a gang to kill them.  When drugs are delivered to a pharmacy, both parties don’t carry weapons to protect themselves.  Instead, they call the police if someone uses violence against them.  But you can’t can’t call the police for help if you’re dealing in illegal drugs.

We need to follow the trend in other states and around the world:  Legalize recreational marijuana and treat addiction using a medical model, just like alcohol.  Let your elected representatives know your feelings.  That is the way to get these unjust laws changed.

Link to Register article: https://www.desmoinesregister.com/story/news/crime-and-courts/2019/01/17/jamaica-mayor-ladonna-kennedy-pot-weed-gurthrie-county-crime-marijuana-search-ames-shooting-suspect/2606455002/

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/