U.S. President Donald Trump in September signed an order that aims to reduce the amount Medicare, the government program for the elderly, pays for some drugs by tying prices to those paid by countries with national health systems. Trump, who has accused drugmakers of “getting away with murder,” has declined to put forward a policy he’d previously backed that the industry feared most: having the government directly negotiate prices. Former Vice President Joe Biden, who is challenging Trump for the presidency, supports that approach, as well as limits on price increases for certain drugs. Outrage at drugmakers has been building in the U.S. Lawmakers have opened probes into how prices are set, and the Justice Department is investigating possible price collusion by more than a dozen companies that make generic drugs. Prescription drug spending in the U.S. surged in 2014 and 2015 after four years of minimal growth due largely to the spread of generic drug use. Specialty drugs (high-cost treatments, mostly for complex conditions) accounted for much of the spike. The current backlash first erupted in 2013 when Gilead Sciences released the groundbreaking hepatitis cure Sovaldi at $84,000 for a 12-week course. The steep price and stampede of patients to get the drug led many insurers to restrict coverage to the sickest patients. With the furor over drug prices rising, the growth in prescription spending declined to moderate levels starting in 2016.
Unlike other nations, the U.S. doesn’t directly regulate medicine prices. In Europe, the second-largest pharmaceutical market after the U.S., governments negotiate directly with drugmakers to limit what their state-funded health systems pay. The U.K.’s National Health Service has refused to pay for some cancer drugs widely used in the U.S. on the grounds that they don’t constitute value for money. In the U.S., drug companies can more or less set whatever price the market will bear. For most outpatient drugs reimbursed through Medicaid, the public health program for the poor, drugmakers must provide rebates to the government. But most medicine costs are paid for by Medicare or by private insurers. When prescription-drug benefits were added to Medicare under a 2003 law, the pharmaceutical industry successfully lobbied to prohibit the federal government from using its huge purchasing power to negotiate drug prices. Private payers typically rely on third-party pharmacy-benefit managers, such as Cigna Corp.’s Express Scripts unit, to negotiate discounts. Often they make exclusive deals with drugmakers, which limits the choice of drugs patients have. In the U.S., patients directly pay about 14% of prescription medicine costs out of their own pockets. In one survey, one in five adults in the U.S. said they failed to complete a prescribed course of medicine because of cost. The figure was one in 10 in Germany, Canada and Australia.
Pharmaceutical companies argue that they need robust profits to bankroll the development of medical advances and that restricting prices would harm innovation. They highlight the benefits of medicines such as Sovaldi, which has a cure rate superior to treatments that cost nearly as much. Critics point to the industry’s fat profit margins and say companies exaggerate drug-development costs. Doctors and insurance executives worry that many medicines are rapidly becoming unaffordable. Advocates of greater price regulation argue that it needn’t hamper innovation. They say drugmakers could reduce spending on marketing and cite an analysis that found promotional budgets exceed those for research and development at most big companies.
The Reference Shelf
• Bloomberg News examines the practices of pharmacy-benefit managers in a series of articles.
• A Congressional Research Service report explores prescription drug pricing and policies.
• An Iqvia Institute report provides data on medicine use and spending in the U.S.
• Pharmaceutical companies defend drug costs on an industry website.
• A Center for American Progress report advances proposals for addressing high drug prices.
• An article in the Harvard Business Review argues that U.S. consumers are footing the global bill for developing new drugs.
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