December 7, 2022

Lisa McCrepley lives with multiple sclerosis for more than a decade. And although the condition eventually forced her to leave the workforce and move from California to be with the family in Michigan, she has remained active — volunteering with MS advocacy groups, participating in church activities — with the help of medications that slow the progression of the disease and reduce it. severity of symptoms;

But the treatment is expensive, and McCrepley’s drug coverage, through Medicare, leaves her with hundreds of dollars, sometimes more than a thousand dollars, in out-of-pocket costs when she fills prescriptions at the pharmacy. Paying is a real hard-income struggle, but not taking medication isn’t an option, McCreble told HuffPost in an interview, as she found out the hard way this summer, when she stopped taking some of her pills briefly and within a week. She began to lose her mobility, dexterity, and sense of balance.

“I lost my ability to hold a fork or spoon to eat—it was like day and night,” McCreble said.

McCreble has resumed taking the medication, but as is often the case with relapsing and remitting forms of MS, she fears it will never go back to where she was. And while McCrepley can’t be sure that stopping the medication is the cause of her worsening condition, she is sure the cost of the drugs will affect her life even when she is able to take them.

“It’s really annoying because I have to ask for help, for things like groceries,” McCreble said. “I’m asking my parents…and I should be in a position where I help them at this time, not the other way around.”

McCrepley’s story is by no means unusual or restricted to people Ms. The higher cost also appears to discourage Medicare beneficiaries with cancer, hepatitis C and certain immune disorders from taking their medications, according to a major research paper published in the journal. Health Affairs earlier this year. This was not the first study Documenting these effects.

Democrats have been promising to help people like McCrepley, and may be on the verge of fulfilling that promise with the Inflation Reduction Act, which party leaders hope to pass in the coming days and send to President Joe Biden for his signature. The legislation includes several provisions aimed at limiting What people pay at the pharmacy. The most famous and Most controversial Among them is what gives the federal government the power to negotiate Medicare drug prices, something that governments of other economically advanced countries already do and a major reason behind the high drug prices in those countries. Much less than they are here.

But only a limited number of drugs will be negotiated under a process that does not lead to lower prices for those drugs until 2026. Until then, drug prices in the United States are likely to remain much higher than in peer countries, which means Medicare beneficiaries Like McRipley they will still need more help, ideally sooner rather than later.

And they might get it. The Other drug fixes than the law to reduce inflation has received much less attention, but many of them may have a significant impact, including one that would put hard limit on me Out-of-pocket drug expenses. It will take more than two years, starting in 2024, so that by 2025, beneficiaries like McCrepley will not pay more than $2,000 a year for drugs that now cost many times that.

This ruling could be a “saviour,” McCrepley said, which, if the studies are correct, is literally true. But it all depends on the bill that has already been passed. As of this writing, this remains unconfirmed.

Medicare Beneficiaries Have Drug Coverage – Big Gaps

The story of why Medicare beneficiaries owe so many prescriptions dates back to 2003, when President George W. Law That created the usefulness of the drugs in Medicare, which is known as Part D. The program addressed a huge need. Before that, Medicare beneficiaries often could not find coverage for drugs.

But the main architects of the program were conservative Republicans and Democrats who refused to give the federal government influence over drug prices and were unwilling to spend what it would take to fund the kind of universal benefit many seniors needed. As a result, part D . contains Big gaps in coverageExposing seniors to large deductibles, co-payments and coinsurance.

The Affordable Care Actwhich was signed by President Barack Obama in 2010, partially addressed the problem by gradually eliminating one of the big coverage gaps — or close the “donut slot”, as it became known. The 2018 bipartisan budget lawsigned by President Donald Trump, hastened the process.

“these [drugs] Not optional for people. This is what you need to extend your life or to prevent you from getting sick.”

– Stacey Dositzina, Associate Professor at Vanderbilt University

But even with these reforms fully implemented, Medicare beneficiaries are still responsible for a fraction of their drug costs with no limit on the total.

The share is small, only 5% once drug spending reaches a certain limit. But some drugs have such a high list — tens, even hundreds of thousands of dollars a year — that the 5% becomes a punishment, enough to deter patients from taking the drugs altogether.

“I think there’s a perception that just because someone is in Medicare, they are covered and most prescription drug and other types of costs are covered,” Amy NilesExecutive Vice President PAN . Foundation, which provides financial assistance to people who cannot afford their medical bills. “But when it comes to prescription drugs, that’s not the case. So for people on Medicare…there is no limit to what you might pay out of pocket for these drugs.”

Sometimes people skip the medication they need

The The study that appeared in Health Affairs earlier this year It shows how severe the effects can be. The researchers found that among Medicare beneficiaries who were not eligible for additional government assistance, nearly 1 in 3 failed to fill new prescriptions.

“We know these are very important drugs, and many of them are top-notch treatment recommendations,” said Vanderbilt associate professor and lead author. Stacy Dusitzina Tell HuffPost. “So these are not optional for people. This is what you need to extend your life or to prevent you from getting sick. The fact that it’s roughly 1 in 3, that’s amazing.”

Not all medications needed by Medicare beneficiaries translate into high individual costs. They are drugs that beneficiaries purchase directly from pharmacies using Part D coverage. Injections and other medications they get in doctors’ offices and clinics usually fall under Medicare Part B, which pays for outpatient services, and the Part B cost-sharing is usually much lower because most recipients have supplemental coverage or out-of-pocket limits on medical spending.

Senate Majority Leader Chuck Schumer (DN.Y.) speaks during a press conference on the Inflation Reduction Act outside the US Capitol on Thursday.  The bill is expected to include three years of support for Affordable Care Act premiums and some prescription drug reforms.
Senate Majority Leader Chuck Schumer (DN.Y.) speaks during a press conference on the Inflation Reduction Act outside the US Capitol on Thursday. The bill is expected to include three years of support for Affordable Care Act premiums and some prescription drug reforms.

Drew Angerer / Getty Images

To illustrate the illogicality of this distinction, Dusetzina He cited breast cancer, for example.

Treatment for one common type, known as HER2-negative cancer, is a medication that people take by mouth. For Medicare beneficiaries, annual personal costs can exceed $10,000. Treating a different type, HER2-positive breast cancer, is an infusion, which for most Medicare beneficiaries will cost a fraction of that amount.

“This means that you may be lucky to have a cancer that is treated with injections rather than pills,” Dusetzina said. “It makes no sense at all.”

Charities provide substantial help, but it is not enough

Joan Dornell Powell doesn’t need a study to tell her about the high cost of drugs and the choices they impose on patients. Powell is retired in California, diagnosed in 2014. Myelodysplastic syndromeclass of blood disorders. She said in an interview that the medications she took kept her alive, but often with out-of-pocket costs of four and five.

Like many Medicare beneficiaries, Powell has received help from several private charities, including the PAN Foundation, which helps people who can’t afford their medications. “Without the support of these institutions, I literally would not have survived.” But sometimes grants expire or paperwork isn’t done, Powell said, and even when the money is there, it just covers some of the bills.

Today, she said, she still has to generate roughly $5,000 to $6,000 a year — on a steady annual income of less than $30,000. “Anytime I tell people about this, I say they don’t have to worry about my illness. I should worry about my joint salary.”

Restrictions on what charities can provide is why these organizations line up Affordable drug patientsAnd the families and other healthcare advocacy groups to support the proposed maximum out of pocket. They are equally excited about some of the relevant provisions in Democratic legislation, including the proposed expansion of support for low-income Medicare recipients.

The repair package has real trade-offs

Like all policy proposals, Democratic legislation comes with some trade-offs, which, in the case of maximum out-of-pocket and low-income aid, are primarily in the form of new government spending.

In other words, the reason Medicare recipients like McCrepley and Powell would pay less for their drugs under the Democratic proposal is that the federal government would bear more of the financial burden directly.

This helps explain why these two articles are part of the same law that calls for the government to negotiate drug prices. Negotiation and some related provisions in the legislation would reduce Medicare spending because as individual drug prices drop, Medicare won’t have to allocate as much money to them.

“You don’t have to worry about my illness. I should worry about my joint salary.”

— Joanne Dornell Powell, Medicare beneficiary in California

The drug industry and its allies, including Republicans and some Democrats, have warned that lowering drug prices would reduce drug companies’ profits, making it difficult for them to attract the venture capital they need to fund research and development for new drugs. It probably means that Fewer miraculous drugssuch as the kind that now treats MS and Powell’s blood disorder.

But analysts in Congressional Budget Office They said they believed the Democrats’ bill would likely have little impact on innovation. and while Lots of researchers Think about the effects can be biggerDusetzina, among a large group who thinks the CBO got it right.

“I think the bill does a good job of finding a balance — putting in safety barriers around which drugs are eligible for negotiation and also targeting only a small number of drugs to start,” Dusetzina said. “So I think the pharmaceutical industry’s claims of missing therapies are greatly exaggerated.”

Of course, the proposal will have no effect on innovation — or on drug prices — if the Inflation Reduction Act is not passed to Congress. And though all 50 senators in the Democratic caucus have now said they support the bill, paving the way for its passage, the pharmaceutical industry is making one last, desperate push to break up the coalition.

Much depends on the outcome. For some Medicare beneficiaries, it may be a matter of life or death.

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