Tom Williams/CQ Roll Call via AP Images
Demonstrators rally in front of the Washington office of PhRMA, a trade group representing the pharmaceutical industry, to protest high prescription drug prices, September 21, 2021.
Politicians of both parties have been promising for decades to lower drug prices; it was part of the “Six for ’06” agenda that Nancy Pelosi used to win the House for Democrats 15 years ago. Now, Democrats are squabbling among themselves about how to get it done. They are fighting over which drugs Medicare should negotiate, how much prices should be cut, and whether commercial insurance payers should be able to benefit from those negotiations.
But behind this technical squabbling are real people struggling to afford medications, which is not limited to seniors on fixed incomes. The price of prescriptions is out of reach for people of all ages and all backgrounds. Women, who are often the ones navigating health care for their aging relatives and for their children as well as themselves, experience the problem from many directions.
When lawmakers make decisions over drug pricing reforms, to millions of Americans they can be the difference between life and death. These stakes have often been neglected, amid an endless cascade of aggressive industry lobbying, attack ads, and political donations.
Take Detroit’s Cindy Fraser, a mother of four, a widow, and her family’s sole breadwinner. Cindy works part-time as a custodian for a church and is a full-time caregiver for her teenage daughter, who has a genetic disorder, celiac disease, arthritis, and Type 1 diabetes.
Cindy’s daughter is insured through the Children’s Health Insurance Program, but they still struggle with the high cost of prescriptions, because not all of her daughter’s medications are covered. They often run into problems with “step therapy,” when their insurer wants them to try a less expensive version of a medication before “stepping up” to a version that will cost more. That’s especially challenging because her daughter has many allergies and often can only tolerate a specific brand of medication.
“Just because you have insurance doesn’t mean you can afford the medication.”
Cindy explained how terrifying it can be to show up at a pharmacy counter, only to learn that the insurance company has approved the insulin brand that your daughter is allergic to, because it is cheaper, instead of covering the version she needs. Meanwhile, the other brand is so costly that Cindy’s family can’t afford it.
Things have been even harder for Cindy during the pandemic. She has had to pause her side jobs to keep her family safe, so her income has plummeted. The fact that her daughter’s $300 ear drops and lifesaving insulin are available at a fraction of the cost just a few miles away in Canada makes her want to scream.
Full disclosure: I know how she feels. When I was pregnant with my now two-year-old son, I had an iron deficiency. My doctor prescribed high-strength iron pills, which would almost certainly have solved the problem, if I had been able to fill the prescription. But with a baby on the way, I couldn’t afford the high out-of-pocket costs. Luckily, my nurses were able to arrange to get me enough free samples to raise my iron levels and avoid the terrifying outcomes I could have faced.
Cindy and I are far from alone. A 2019 Gallup poll found that 58 million adults in the U.S. reported being unable to pay for drugs they needed in the last year. In the same poll, more than 13 million adults reported that, in the last five years, they knew at least one friend or family member who died after not receiving medical treatment they were unable to pay for.
Similar to Cindy, Lafleur Duncan is a small-business owner and a mother of two in Brooklyn. Her 14-year-old has asthma, and the cost of his medication is high. His inhaler alone comes with a $45 co-pay. She worries about how they’ll manage if he has another outbreak.
“Just because you have insurance doesn’t mean you can afford the medication,” Duncan said. “My son’s meds are lifesaving, but the cost has skyrocketed. Money shouldn’t be a barrier for health care. I want to see my elected leaders stand up for us and take action to lower prescription drug costs.”
Michael Eddins, a retiree from North Carolina, told the Prospect about how he has a chronic condition that requires prescription drugs for management. The cost was out of his budget, but he received a stroke of luck: The drug he was taking went off-patent, allowing him to get a cheaper generic for $136.57 per month in co-pays after hitting the deductible.
For 2021, he enrolled in a new Medicare Advantage program, an HMO with Aetna, on the advice of an insurance representative. But in March, he learned that his co-pay for that generic drug would rise to $682.59 per month. He was stunned.
Eddins was told by Aetna that he could get the lower price if he dropped the HMO and went back to a PPO. But nobody could explain why a generic product would spike over fivefold in a few months, based only on which insurance plan of the same company Eddins had. “The common assumption that generic drug costs are lower than brand-name drugs (attested by one month in December 2020) is therefore a gross falsehood,” Eddins explained.
The three measures in the Democrats’ model reform and endorsed by President Biden include allowing Medicare to negotiate prescription drug prices, capping out-of-pocket costs for Medicare beneficiaries, and penalizing pharmaceutical companies that raise prices faster than inflation. All of the patients in this story would be helped by such reforms, and see the cost burdens for their medications go down. Policies like these are overwhelmingly popular among voters because working people across party lines are struggling to pay for medications they need to survive.
Members of Congress who have resisted prescription drug reforms often say that their ideas strike the right balance between helping people and supporting new cures. But every dollar in profit allowed to flow into the hands of the pharmaceutical industry is a dollar that Michael Eddins, or Cindy Fraser, or Lafleur Duncan, or I must pay. And those are dollars that many Americans simply don’t have.
