Medicare drug price negotiation can’t come soon enough for some Mainers

Ronald Hopkins takes over 20 different prescription drugs. But one medication in particular causes the 88-year-old Searsport resident the most financial stress.

Hopkins takes the medicine Jardiance to treat congestive heart issues. But that prescription comes at a steep cost. For his latest 90-day supply, Hopkins — who has insurance through a Medicare plan associated with United Healthcare — paid $1,266 out of pocket. That didn’t even represent the full cost of the medication, as his insurance kicked in the remaining $866. But that contribution means that Hopkins has now maxed out what his insurance will cover for medications over the course of an entire year, leaving him to figure out how to pay for the rest of his prescriptions in 2023 on his own. 

Although Hopkins, who gets by on Social Security income and money from investments, qualified for a $1,200 grant to help him out, those are one-time funds that he said are a drop in the bucket compared to his overall prescription drug costs. 

“I pay my taxes. I own my home. But I don’t know how much longer I’ll own it at this rate,” he said. “I’m between a rock and a hard place.”

Hopkins is not alone in struggling to afford the cost of Jardiance, which is a product of Boehringer Ingelheim and Eli Lilly. From July 2021 to June 2022, it was the 13th costliest drug for Mainers, with people around the state paying more than $17 million collectively for the medication. Mainers paid an additional $93 million for the second most costly drug on that list, the blood thinner Eliquis, another $87.5 million for Crohn’s disease treatment Stelara and $35 million more for the arthritis medication Enbrel.

Along with being expensive, though, these drugs have something else in common, as each is among the 10 prescription medications that the Biden administration recently announced will be subject to price negotiation by Medicare in an attempt to bring down skyrocketing costs that create a financial burden for people like Hopkins.

Signed by President Joe Biden in August of last year, the Inflation Reduction Act (IRA) allows Medicare to begin price negotiation for some drugs, which the public health insurance program has historically been barred from doing. The measure also caps insulin costs at $35 per month for those with Medicare insurance and will provide recommended vaccines to people covered by Medicare for free. Overall, the price negotiation policy is projected to help reduce health costs for around 9 million Americans. 

The move comes as people in the U.S. are subject to some of the highest prices in the world for prescription drugs, paying 2.8 times as much as Canadians do for some medications. At the same time, the pharmaceutical industry — which has launched several lawsuits against Biden’s Medicare price negotiation policy — rakes in billions annually even as an estimated 18 million Americans can’t afford the cost of prescription drugs. 

The high costs have affected many people in Maine, with a December 2022 survey released by Consumers for Affordable Health Care finding that 1 in 4 people in the state had rationed pills, skipped doses of a medicine or not filled a prescription due to price and that 52% were concerned about not being able to afford a prescription drug they need.  

Given that situation, local advocates say the bargaining provision within the IRA could be transformative for many of the roughly 364,000 Mainers enrolled in Medicare, although consumers will likely only see costs begin to lower around 2026 for the drugs selected for price negotiation. (Those drugs include Eliquis, Enbrel, Entresto, Farxiga, Imbruvica, Januvia, Jardiance, Fiasp and NovoLog insulin products, Stelara and Xarelto.)

“This is a landmark, monumental piece of legislation. It’s going to have a very direct and serious impact on the lives of thousands,” said Noël Bonam, state director of AARP Maine. 

Bonam noted that, like Hopkins, some older Mainers currently pay several thousands of dollars a year for prescription drugs — a significant chunk of money, particularly if someone is living off a Social Security benefit. 

“Some of these are life-saving drugs, and one has to decide if they are going to turn down the heat really low so they can save some money there and spend it on their prescription drugs or skip a meal each day just so they can take one or two of those drugs that they need,” he said.

‘A good starting place’ 

The 10 drugs on the initial list released by the Biden administration represent only the beginning of the price negotiation policy, as the federal government plans to continue adding medications to the program over the years. Up to 80 drugs could be subject to the price negotiation initiative by 2030.  

Rosalyn Fisher, an 85-year-old AARP member who lives in Bangor, is one of many Mainers who could be impacted by the addition of more drugs to the Medicare price negotiation list. Fisher said she currently takes several medications but that none of them are among the 10 initial drugs included. 

While Fisher said she hasn’t struggled with the price of prescription drugs as much as some people, she estimates that she pays several hundred dollars a year for her medicines. However, she said the bigger issue is that the cost of some of the drugs she takes can fluctuate widely from month to month, with one such medication sometimes going from $3 to $20. 

“I think that whole system is wrong,” Fisher said.

She added that she’s excited for Medicare price negotiation to move forward and hopes to see the list of medications expanded.

“It should have happened when the bill was written, when Medicare was first written,” she said of allowing price negotiation. 

Biden administration chooses first 10 drugs for Medicare price negotiations

Another supporter of the price negotiation initiative is fellow AARP member John Farina of Lewiston. Farina, who worked for 33 years as a pharmacist at the U.S. Department of Veterans Affairs’ Togus Medical Center in Augusta, pointed to findings that the VA’s power to negotiate drug prices helped lower costs for the agency, with a 2017 study examining a sample of 399 drugs showing that the VA paid 54% less per unit than Medicare and that 106 of those medications were at least 75% cheaper for the department than for Medicare.  

Farina said he expects similar benefits for Medicare and its recipients when the IRA’s price negotiation initiative gets going. 

“The government is going to save money in the long run,” he said. “The only people who are against this are the drug companies, Big Pharma, because they’re going to lose profits. They’ve been milking the government for years, and I think it’s about time that the government starts saving money on this and utilizing the money for other things.” 

Ann Woloson, executive director of Consumers for Affordable Health Care in Maine, also believes the reform will be a big deal. 

“We’ll have to see what happens over time in terms of what they negotiate for prices, but it is a pretty good initial step to addressing rising prescription drug costs, not only across the country but for Mainers,” she said. “It’s a good starting place.” 

Still, going forward, Woloson and other advocates say there are additional changes the government could pursue to further improve the prescription drug system, including making it easier to see what prices people are paying in other countries like Canada.

Woloson said she does worry about the series of lawsuits levied against the Medicare price negotiation policy by the powerful pharmaceutical industry. But she noted that given that the U.S. pays more for prescription drugs than any other wealthy country in the world, the current situation is unsustainable and must be addressed.

“There’s got to be something we can do to control prescription drug prices, especially when public dollars are being used to pay for those drugs,” Woloson said.