This is the most underappreciated part of the Democratic prescription drug bill.

Lisa is living with Macripelli. Double stiffness For more than a decade. And though the condition eventually forced her to leave the workforce and move from California to Michigan with family, she has remained active — volunteering with MS advocacy groups, participating in church activities, – With the help of drugs that slow the progression of the disease and reduce the disease. Severity of symptoms.

But treatment is expensive, and McRipley’s drug coverage through Medicare leaves her with hundreds of dollars, and sometimes more than a thousand dollars, out of pocket when she fills prescriptions at the pharmacy. Making payments on a fixed income is a real struggle, McRipley told OlxPraca in an interview, but going without medication isn’t an option, as he discovered the hard way this summer, when he briefly And stop taking some of your pills within a week. Loss of mobility, dexterity and sense of balance.

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

McRipley has resumed taking medication, but, as is often the case with MS relapses and relapses, she fears she will never get back to where she was. And while McRipley can’t be sure that stopping the medication made her condition worse, she’s sure how the cost of her medication affects her life even as she Can take them.

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

McRipley’s story is by no means unusual or limited to these people. Mrs. High costs discourage Medicare beneficiaries with cancer, hepatitis C and certain immune disorders from taking their drugs, according to a large paper published in the journal. Health matters earlier this year. And this was not the first study. Document such effects..

Democrats have been promising to help people like McRipley, and they may be on track to deliver on that promise with deflationary legislation, which party leaders are expected to pass in the coming days and President Joe Hope to send it to Biden for his signature. The legislation includes several provisions designed to reduce What do people pay at the pharmacy counter?. The most famous and Most controversial Among them, the federal government would have the authority to negotiate the prices of drugs covered by Medicare, which governments in other economically developed countries already do, and would set a price cap for drugs in those countries. Big reason Very Low More than they are here.

But only a limited number of drugs will be subject to negotiation under a process that will not lead to price reductions for these drugs until 2026. That means Medicare beneficiaries like McRipley will still need more help, ideally sooner rather than later.

And they can get it. gave Other Prescription Drug Reforms The law of deflation has received little attention, but several can have major effects, including one A hard limit On Out-of-pocket drug costs. It would be phased in over two years, starting in 2024, so that by 2025, beneficiaries like McRipley would pay no more than $2,000 a year for drugs that cost many times that now.

McRipley said the provision could be a “life saver,” which, if the studies are correct, is literally true. But it all depends on the actual passage of the bill. As of this writing, that’s still not a foregone conclusion.

Medicare beneficiaries have drug coverage — with big differences

The story of why Medicare beneficiaries owe so much for prescriptions goes back to 2003, when President George W. Bush signed it into law. Law That created Medicare’s drug benefit, known as Part D. The program filled a great need. Before that, Medicare beneficiaries often couldn’t get drug coverage.

But the program’s chief architects were Republicans and conservative Democrats who refused to let the federal government leverage drug prices and were unwilling to spend what it would take to finance such a comprehensive benefit. Many seniors need As a result, part d is Big gap in its coverageEducating seniors about important deductibles, copayments and coinsurance.

gave Actionable precautionssigned into law by President Barack Obama in 2010, partially addressed the problem by phasing out a large gap in coverage — or Closing the “donut hole”. As it turned out. gave 2018 Bipartisan Budget ActSigned by President Donald Trump, the process accelerated.

“This [drugs] Not optional for people. These are the things you need to prolong your life or prevent you from getting sick.

– Stacie Dusetzina, associate professor at Vanderbilt University

But even with these reforms in place, Medicare beneficiaries remain responsible for a portion of their drug costs with no total cap.

The share is small, only 5% once drug spending reaches a certain threshold. But the list prices of some drugs are so high — tens, even millions of dollars a year — that the 5% becomes a penalty, enough to deter patients from taking the drugs altogether.

“I think there’s this perception that just because someone is on Medicare, they’re covered and most of their prescription drug costs and other types of costs are covered,” said. Amy NilesExecutive Vice President of 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’s no limit to what you can pay out-of-pocket for those drugs.

Sometimes people skip the medication they need.

gave A study published earlier this year in Health Affairs Shows how severe the effects can be. Among Medicare beneficiaries who were not eligible for supplemental government assistance, nearly 1 in 3 were failing to fill new prescriptions, the researchers found.

“We know that these are very important drugs, many of them are first-line treatment recommendations,” Vanderbilt associate professor and lead author Dr. Stacey Dusitzina told OlxPraca. “So these are not optional for people. These are things you need to extend your life or prevent you from getting sick. The fact that it’s almost 1 in 3, it’s just mind-blowing. is a giver.

Not all Medicare-covered drugs translate into such high individual costs. These are primarily drugs that individual beneficiaries purchase directly from pharmacies using their Part D coverage. Infusions and other drugs they get in doctor’s offices and clinics are usually covered by Medicare Part B, which pays for outpatient services, and Part B cost sharing is usually very low. This happens because most beneficiaries have additional coverage or out-of-pocket limits. medical expenses.

Senate Majority Leader Chuck Schumer (D-N.Y.) speaks outside the U.S. Capitol on Thursday during a news conference about the Anti-Inflation Act. The bill is expected to include three years of subsidies for Affordable Care Act premiums and some prescription drug reforms.

Drew Engerer/Getty Images

For an illogical explanation of this distinction, Dusetzina has An example of breast cancer was given..

A common type of treatment, called HER2-negative cancer, is a drug that people take orally. For Medicare beneficiaries, annual out-of-pocket costs can exceed $10,000. A different type, HER2-positive breast cancer treatment is an infusion, which will cost a fraction of that amount for most Medicare beneficiaries.

“It means you’re feeling lucky that you have a cancer that’s treated with infusions instead of pills,” Dusetzina said. “It doesn’t make any sense.”

Charities provide important support, but it is not enough.

Joan Durnell Powell doesn’t need a study to tell her about the high cost of medicine and the choices it makes on patients. Powell is a retiree in California who was diagnosed in 2014. myelodysplastic syndromes, a class of blood disorders. He said in an interview that the medications he took kept him alive, but with out-of-pocket costs that ran into four and often five figures.

Like many Medicare beneficiaries, Powell has received support from several private charities, including the PAN Foundation, which helps people who cannot afford their medications. “If it wasn’t for the support of these foundations, I literally wouldn’t be alive.” But sometimes grants expire or the paperwork doesn’t go through, Powell said, and even when the money is there, it only covers some of the bills.

Today, he said, he still has to get by on a fixed annual income of about $5,000 to $6,000 a year — less than $30,000. “Whenever I tell people about it, I say I don’t have to worry about my illness. I have to worry about my co-pay.

The limitations of what charities can provide is why these organizations have aligned. Patients for affordable medicines, Families USA and other health care advocacy groups that would support the proposed out-of-pocket cap. They are equally enthusiastic about some related provisions in the Democratic legislation, including a proposed expansion of co-payments for low-income Medicare beneficiaries.

There is real trade-off in the reform package.

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

In other words, Medicare beneficiaries McCarplay and Powell could soon pay less for their drugs under the Democratic proposal because the federal government would directly bear more of the financial burden.

That helps explain why those two provisions are part of the same bill that requires the government to negotiate drug prices. The negotiations and some related provisions of the legislation would reduce Medicare spending because as individual drug prices come down, Medicare won’t have to pay as much for them.

“I don’t have to worry about my illness. I have to worry about my co-pay.”

– John Darnell Powell, a Medicare beneficiary in California

The drug industry and its allies, including Republicans and some Democrats, have warned that forcing drug prices down would cut into drug company profits, making them less attractive for investment capital. It will be difficult to do what they need to finance the research and development of new drugs. It could possibly mean. Less developed drugsAs it now treats McRipley’s MS and Powell’s Blood Disorder.

But the analysts Congressional Budget Office have said they think the Democratic bill will likely have little impact on innovation. And while Many researchers Think the effects Can be biggerDusetzina is among a large group that thinks CBO got it right.

Dusetzina said, “I think this bill does a good job of finding a balance — putting guards around what drugs are eligible for the conversation and targeting only a small number of drugs to begin with. Dusetzina said. “So the pharma industry’s claims of therapeutic harm are, in my view, dramatically overstated.”

Of course, the proposal won’t have any impact on innovation — or drug prices — if the Deflation Act doesn’t get through Congress. And although all 50 senators in the Democratic caucus have now said they support the bill, clearing the way for its passage, the drug industry is making a last, desperate push to break the coalition.

A lot rides on the results. For some Medicare beneficiaries, it can be a matter of life or death.


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