When someone says ‘it’s complicated’ ….

That often means “I don’t know,” or “It’s none of your business.” But nothing significant is ever simple or easy and that is particularly true of health costs in America.

We are again immersed in a quadrennial flood of promises to make health care and medications at once less costly and more accessible. Most propose simplistic solutions backed by assertion that the problem is “greedy doctors, hospitals, and pharmaceutical companies,” “greedy insurance companies,” or “incompetent government meddling.” It doesn’t take great insight to understand that none of these is the problem, but all of them are.

One advertisement featuring Sen. Susan Collins highlights the devastating increases in the cost of insulin over the past decade. A bill she sponsors (S.2199) will prohibit “pharmacy benefit managers and insurers from receiving rebates for insulin products” when the manufacturer has reduced the list price to the 2006 price. That is quite a word salad and the words mostly do not mean what one would think. It takes knowing a good bit about that market to decode what is being done.

Few, if any of us knew there was such a thing as a pharmacy benefit manager or PBM. These “middleman” companies negotiate rebates on mostly brand name drugs and pass on (some of) the savings to insurance companies, not to pharmacies or consumers.

President Trump proposed changing the rules to eliminate PBM kickbacks for Medicare and Medicaid but withdrew that proposal in the face of strong resistance and an assessment by the Congressional Budget Office that blocking the kickback regime would result in higher prices paid by Medicare and Medicaid and higher insurance premiums for everyone. It’s rather murky who really benefits from the rebate scheme, but it is certain that the consumer does not. The uninsured and those buying their medications with “deductible” dollars pay the fully inflated price.

A federal judge sustained a challenge to another administration proposal that would have required drug manufacturers to advertise their actual list prices. Curiously, the opposition came not from drug manufacturers but from PBMs and insurance companies (Kaiser Health News, July 12, 2019). Even more curious is that search engines return nothing regarding the decision rationale or even a specific citation.

As would be expected, the usual culprits published hit pieces last summer shrieking that Trump had abandoned the vulnerable and caved to special interests. But it is complicated, and the truth is that we — through past legislation permitting and protecting this kickback scheme — created a mess that cannot be easily dismantled without unforeseen consequences.

Worse yet, in this election year legislators are unlikely to risk making changes with unpredictable consequences and the administration is fighting a push by Democrats for an expedited Supreme Court decision they hope will overturn the lower court ruling that the Obamacare individual mandate is unconstitutional.

The patient price for insulin is just one manifestation of the hideous web of rules and practices created by providers and insurance companies to escape scrutiny, frustrate regulation, avoid competition and ensure profitability. Undoubtedly the complexity is deliberate, but that the PBMs and insurance companies (some of whom own PBMs) are at the forefront of opposing price transparency is telling. Lobbying groups may spend as much effort and money to prevent any action as to promote one. Keeping the public and the media focused on assigning fault extends the status quo, precisely the goal of PBMs and their client insurance companies.

While some argue that insulin is a 100-year-old product, the fact is that the product today is nothing like what was discovered in 1921. The often cited 10-to-1 markup may be real or it may ignore the very real costs of researching new formulations and developing modern production facilities. None of those costs are published and audited. There is no true competition among producers or PBMs and insurance providers. Most of all, nobody has anything to gain by representing the consumer, but everyone other than the consumer has potential losses if the status quo is disrupted and much to gain from blame shifting.

President Trump has promised and acted to dismantle the kickback scheme. His efforts thus far have been resisted and frustrated; the status quo remains for another year. That is no less true of care provided in hospitals, clinics and other facilities. It’s complicated: Disruption may come quickly, but meaningful change will take time and unprecedented cooperation and deliberation.

If ever there was a case for voters to be careful what they wish for, this is one. Few will take the time to do the reading to be even minimally informed. All will hear specious, disingenuous promises and vicious blame shifting. In the end, even the most informed and deliberative voter will be left to decide who they trust and hopefully that will be based more on what the candidate has done than on what he or she has said.

Sen. Collins is not seen on talk shows shifting blame. She gathers information and then decides based on facts and instinct.

We could do much worse than elect those who follow her approach.

Another View is a weekly column written collaboratively by Dale Landrith of Camden, Ken Frederic of Bristol, Paul Ackerman of Martinsville, Jan Dolcater of Rockport and Ralph “Doc” Wallace of Rockport.

Swiftype Reports

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