As with other insurance, it is the RISK of needing expensive care, services, devices and, in this instance, drugs to regain and-or maintain health that is the measure of the effectiveness of any insurance policy.
With its lists of low-hanging fruit of service contract type inspection-style checkups and screenings combined with the permission to raise prices to consumers for treating anything discovered, Obamacare nationalized a policy of greater financial and physical risk for consumers by establishing MINIMUM standards when Obama partnered WITH rather than TOOK ON insurance companies for Obamacare.
This is not supposition, but fact as we know it, that Obama embraced the insurance lobby's proposition to help Obama fulfill a flashy political promise of illegalizing denial of health insurance for those with pre-existing conditions AS LONG AS he also committed to using the power of the federal government to force everyone to purchase health insurance…the individual mandate with ample room for insurance companies to raise out of pocket costs for needed care in the form of deductibles, copays, coinsurance and exclusions.
We know that Obamacare raised costs of using health insurance from report after report and because Obamacare's strategy as revealed by Obama's own Congressional Budget Office indicated that rather than using government to strengthen "negotiations" with insurers and obtain the best options for healthcare plans on Obamacare exchanges on behalf of consumers that instead, in partnership with insurers, Obamacare perpetuated and embraced the insurance company game of narrow networks and restricting patient usage of insurance.
So, in 2015, we were informed by Obama's Administration: "Plans initially offered through the exchanges appeared to have, in general, lower payment rates for providers, narrower networks of providers, and tighter management of their subscribers’ use of health care than do employment-based plans. CBO, Pub. 49973, page 22)."
We also know that Obama basically left big pharma free to do what they've done, raise their prices on more and more drugs putting them out of reach for consumers even as insurers cover FEWER and FEWER of them.
As explained in many places, but specifically in THE HILL on December 15, 2016, by Peter Sullivan: "Obama administration scraps controversial drug pricing proposal," because "[T]he proposal had faced intense opposition from the powerful pharmaceutical lobby, but also from other areas, like doctors groups."
And so, we consumers face ongoing UNDER-INSURANCE, having insurance but still unable to pay for necessary prescriptions to regain-maintain health.
Against this backdrop we get the Des Moines Dems' ideas which will perpetuate and could WORSEN the under-insurance problem of prescription drugs, because of their inability or unwillingness to take on the pharmaceutical industry.
The most time was spent by candidates talking about giving the government the power to NEGOTIATE on behalf of Medicare. While this addresses a current specific prohibition against negotiation on price by government on behalf of Medicare with big pharma, NEGOTIATION is not enough for consumers.
Too often "negotiation" is used by politicians as a throw-away word to protect themselves against failure…"We meant well, but we failed." This worked very well for Obama whose long list of failures were never attributed to bad intention, regardless of the evidence that emerged.
As important as empowering the government to "negotiate" is the requirement there be a clear indication of who they're negotiating on behalf of and what the specific minimum deal they're willing to accept is. This means consumers need more information.
We have our current state of under-insurance for drugs necessary to regain-maintain health and unfortunately,the candidates are still in the Obamacare mindset whereby consumers are supposed to look at long lists of formularies and be impressed rather than notice what's not covered, typically the most expensive prescriptions they MIGHT need to regain or maintain health AND have their insurance product do what it's supposed to do, use consumer money in the form of premium or taxes to cover that RISK.
Without this, we get what we have and worse, paying insurance companies and they're simply keeping that money without paying out for the most expensive needed medical services, devices, drugs, arguably the only reason we need insurance. Worse becomes obvious when we consider the tremendous taxation increases that come from the candidates with their same-old ideas.
Every time we see the "FORMULARY" lists, consumers should be alarmed because we know that by providing a long list of "covered stuff" that likely the most expensive drugs are not included. This is more critical under today's Medicare and under the Sanders Medicare For All because there is NO OUT OF POCKET MAXIMUM for excluded services or drugs. That's why the Sanders bill has private insurance contract provisions, completely outside of government. So, when we see a list, we know we're being conned about "coverage."
To date and through Obamacare, we've been advised to read through these formularies to see if our drugs are on them before we enroll in a plan and we've tolerated this bit of exploitation. Exploitation, because most commonly, we're buying insurance pre-diagnosis, and we're anticipating that INSURANCE works as insurance and covers our risk, otherwise they're just taking money.
Second, even if we have pre-existing conditions requiring a drug, we are not able to pre-determine whether there's a drug that will become FDA approved and become the gold standard during the year, or whether there's another omitted drug that will become necessary because of a drug recall, or whether our drug will be dropped in the next benefits year, and so on. For consumers, formularies are a loser's game.
So formulary peddling is a means of payers controlling THEIR costs, not OURS and if you listen beyond the bragging, the insurance lobbyists and pharmaceutical lobbyists are going nowhere, and the politicians are not standing up to either.
We'll start with Bernie Sanders' Medicare For All Plan because it's actually already a bill in Congress. A good summary of Sanders' plan is much like an HMO, "We'll give you some services and some providers and some drugs, but anything outside what we give you, you're on your own." There is no out of network protection at all.
Sanders provides for the Secretary to determine those drugs that will be covered by Medicare For All, also empowering the Secretary under Sec. 614(b)(4), Payments for prescription drugs and approved devices and equipment, "USE OF OFF-FORMULARY MEDICATIONS.—The Secretary shall promulgate rules regarding the use of off-formulary medications which allow for patient access, but do not compromise the formulary."
This seems to indicate empowering the Secretary even more authority to further place hurdles in front of consumers to obtain even the formulary-approved drugs.
Senator Elizabeth Warren supports the Sanders bill but also floats out the idea of maybe having the government create competition with big pharma by running its own manufacturing by contracting out the manufacturing of generics.
But, Warren's big talk comes up empty as anything but a political manipulation for setting the stage for an Obama-like, "I tried and failed," instead of a real plan. Why? First, because in her brief statements she mentioned only three drug types where she was determined to make drugs more affordable, epi-pens, insulin, and HIV-AIDS drugs. That group was mentioned twice, they won the Warren lottery.
Secondly, Warren's idea for a government drug manufacturer is based on her statement that "…there are a whole lot of drugs, about 90 percent of drugs that are not under patent they're generic drugs. But the drug industry has figured out how to manipulate this industry to keep jerking the prices up and up and up."
However,Warren makes no statement that the imagined government generic drug manufacturer will manufacture all those 90 percent of drugs off-patent would be part of the manufacture, and therefore, like the three drugs Warren names twice, consumers are left hoping their prescription necessary for regaining-maintaining health makes the formulary.
Further, Warren makes it very clear she's not going up against big pharma through the use of price controls, a direct way that government can legislate access to needed prescriptions: "My view is, let's give them a little competition. The government lets contracts for all kinds of things, to build buildings, to build military weapons. Let's let the contracts out so that we can put more generic drugs out there and drive down those prices. Not to try to move away from the market, you don't even have to use price control get drug generics down."
Got it? NOT to try to move away from the market…and "YOU DON'T EVEN HAVE TO USE PRICE CONTROL."
VP Joe Biden seems to want to continue the misery we have. He states, "The proposal I lay out does in fact limit drug costs. It allows Medicare to negotiate with drug companies for the price it sets, a system where you cannot raise the price of a drug beyond the rate of inflation."
Not good for consumers. There is no evidence that government "negotiates" well and while Biden says his "negotiation" will provide for the formulary Medicare drug prices not to go up beyond the rate of inflation, we already know or should know that this means the formulary will shrink for Medicare as big pharma preserves its profits.
Mayor Pete Buttigieg is onboard with the idea to "Allow Medicare to negotiate prescription drug prices."
Further, Pete Buttigieg states: "On prescription drugs we'll have an out of pocket cap even if you don't get the subsidies that would make it free a $250 monthly cap." (That applies to those on Medicare For All Who Want It, and so again, means that the rest of the population is in the same position they were, or worse, because of rising drug prices.)
Obviously, we know or should know that we can also anticipate shrinking formularies as big pharma preserves its profits.
Senator Amy Klobuchar is dreaming small and uses her track record of failure to support it.
She bragged, "And if you talk…about Medicare and having negotiation, I actually have led that bill for years. I have 34 cosponsors. As president, I can get it done--Medicare can negotiate and lift the ban that big pharma got into law that says they can't negotiate better prices for our seniors. I will get it done."
So, admitting that the effort to lift the government ban on negotiation on behalf of Medicare with big pharma has been an utter failure FOR YEARS, Klobuchar makes the leap that somehow as president, she WILL GET IT DONE. Her idea promises more formularies and shrinking formularies with a vague strategy of "negotiation for better prices for seniors."
Tom Steyer stated: "Between what Senator Warren and Senator Sanders said it's clear there are two problems. We're spending way too much, because corporations own the system and we're not negotiating with those corporations and we've given tax cuts to the richest Americans and the biggest corporations for decades…"
OK, so the two problems for Steyer are too much spending (on the part of whom, government or consumers?) and tax cuts to the richest Americans and biggest corporations.
Steyer recommends: "We need to redo Washington, DC and actually take back the government from the corporations who bought it." Steyer's comments, at best, to me, are an unclear contribution to the big pharma discussion.
So what are consumers looking for? Again, if the problem is as Elizabeth Warren stated it, "I started this by talking about 36 million Americans including Americans with insurance who just can't afford to have a prescription filled," the very definition of under-insurance, then the solution must move towards insurance, which we pay for through direct premiums or taxes, that MUST cover the risk of the cost of needed prescription drugs to regain-maintain health.
Obviously, repeating the mistakes of Obamacare on health services, providing a whole bunch of low-level coverages to make up formularies, lists that include certain drugs and exclude others, is bad, a lottery approach to health care much like any list of services.
The major problem with such lists is first of all, insurance companies forced to cover SOME things will, make up those profits somewhere else. Same thing with big pharma, if they're forced to offer certain formulary drugs for cheap, then they'll make it up by raising prices elsewhere.
Piecemeal legislation will make the cost barrier to needed drugs worse for people not lucky enough to land on the winning side of the lottery of "covered" drugs.
So underinsurance is caused by high pharma prices and poor insurance company coverage, much like the problems we have with needed medical services. And, just as is necessary in healthcare reform for those under-insurance problems, governmental authority and power should be used to control the COST of drugs, through price controls, fines, penalties, loss of tax benefits for pharmaceutical companies that fail to cover the most expensive effective drugs for regaining and maintaining health AND…
Government should be using its authority and power to require that insurance companies provide coverage for the most expensive medically necessary prescription drugs.
Anti-monopoly enforcement, price-gouging enforcement, national price controls on any medication, even those under patent, SOMETHING to rein in big pharma.
OR, in terms of a single payer, government, not some new minimum standard junk plan like Obamacare, but instead start at the other END the ridiculously expensive needed medical services and care that are becoming more and more out of reach for consumers, a catastrophic government prescription plan available to individuals with drug needs that exceed a certain percentage of income, where the federal government picks up any cost beyond 20, 30, percent of a family or individual's income.
OR, caps on any prescription drug, not simply those in the formularies (as Buttiegieg supports) with a policy understanding that big pharma will undoubtedly raise the costs of all drugs to reach that cap thereby making every prescription drug cost $250 a month.
Further, lifting the negotiation ban will do nothing without strict requirements of the limits of how much negotiators negotiating on our behalf can give up in order to obtain their deals with big pharma. It's a fool's game to authorize a negotiator with no limits, so that the negotiator can come back with any deal for the sake of saying, "There's a deal," which only bolsters their ego without assuring that it actually IS a deal we can live with.
Similarly, if there is no strategy and methodology for negotiation to reach specifically defined goals, then it's simply an Obama like political maneuver to show, "I meant well, but I failed."
