Prognosis - Trump Eyeing ‘Disruptive’ Changes to Drug Pricing, Health Secretary Says

By Cynthia Koons and Anna Edney

September 12, 2018, 12:59 PM EDT Updated on September 12, 2018, 1:37 PM EDT

The Trump administration is looking to make “disruptive” changes to U.S. drug pricing to bring down costs for patients, Health and Human Services Secretary Alex Azar said.

“Every player in the system has their share of blame,” Azar said in an interview at Bloomberg headquarters in New York on Wednesday, adding that he’s working on overhauling the system. “Part of that is going to be some fairly large, disruptive changing of the rules of the road.”

The administration has taken aim at the list prices of prescription drugs, and some drugmakers have pulled back from proposed hikes in recent months. Pharma companies have long pointed to the role of middlemen such as pharmacy-benefit managers in pushing drug prices higher. PBMs collect rebates from drugmakers in exchange for preferred status on drug plans, which helps boost sales of their products.

“Pharma companies set their price,” said Azar, a former pharmaceutical industry executive. “They may be doing so within an economic system that has various incentives, and my job is to change the system.”

He was careful not to single out PBMs as the sole reason the system is working the way it is.

“I am not blaming pharmacy-benefit managers for the position we are in around drug pricing or the dynamic of rebates,” he said. “The pharmacy-benefit managers do an incredible job negotiating discounts, rebates in our system. In fact, a major part of the president’s plan is that we’re further empowering pharmacy-benefit managers,” referencing Medicare drug programs for the elderly.

In August, Health and Human Services granted private insurers, which provide coverage to about 20 million seniors through Medicare Advantage, new powers to bargain over drugs administered in doctor’s offices or hospitals. The government and consumers in those plans spent $25.7 billion in 2015 on drugs administered in a doctor’s office or hospital.

Azar also said the rebate system could potentially be replaced in part by discounts that consumers receive at the pharmacy counter.

In July, HHS submitted a proposal to the White House that would curb kickback exemptions that allow drugmakers to offer insurers and pharmacy-benefit managers rebates. Details of the proposal weren’t available, but its title provides a clue to the changes being considered: “Removal Of Safe Harbor Protection for Rebates to Plans or PBMs Involving Prescription Pharmaceuticals and Creation of New Safe Harbor Protection.”

Sweeping Shift

It could represent a sweeping shift in how drug prices are set in the U.S. and potentially eliminate some of the opacity that surrounds the system. Azar wouldn’t comment specifically on what was in the proposal.

“There will be margins, there will be businesses,” he said, implying the changes aren’t designed to dismantle companies. “They will reorient their business models and the channel will reorient around any changes we make to the rules of the road.”

Regulators have also been focused on how to increase the use of biosimilars, which are less expensive copycats of high-priced biologic drugs that often cost in the tens of thousands of dollars. Makers of these lower-cost alternatives have said that incentives in the system have made it challenging for them to compete against brand-name equivalents.

Azar said his ultimate desire would be to make it so that pharmacists could freely substitute cheaper biosimilars for their high-priced counterparts.

He’s seeking to create as “robust” a market for biosimilars as exists for generic drugs, without laying out a specific timeframe for this initiative.

The introduction of biosimilars was expected to cut billions of dollars in drug spending from the health-care system but some drugmakers say it hasn’t worked that way. Drug giant Pfizer Inc. is currently suing rival Johnson & Johnson over what it argues is anti-competitive behavior that has prevented patients from taking Pfizer’s less-expensive version of J&J’s blockbuster Remicade.

— With assistance by Blake Dodge, Jared S Hopkins, and Robert Langreth

(Updates with information about impacts to companies in eleventh graf.)


Ruling allows for purchase of cheaper insurance

Feds ease rules on cheaper coverage, sparking consumer warnings on benefits

August 1, 2018 By  Andy Miller

Fewer benefits. Riskier coverage. Buyer beware.

The Trump administration issued a final rule Wednesday that promotes the sale of more “short-term’’ health plans, but the move immediately drew criticism from consumer advocates and health care industry organizations.

The short-term plans don’t have to cover pre-existing conditions and can provide a limited range of benefits. Many such plans do not cover prescription drugs, maternity care, mental health or substance abuse treatment. The tradeoff is that the premiums are cheaper.

The White House action allows people to buy limited-duration health coverage that lasts up to 12 months and renew that coverage for a maximum of 36 months. The Obama administration, citing consumer protections, had limited such plans to less than three months, and they were not renewable.

President Trump has touted the rule change as producing “much less expensive health care at a much lower price. We’re finally taking care of our people.”

The administration estimates that premiums for a short-term plan could be about one-third the cost of comprehensive coverage required under the ACA.

A short-term plan “is cheap, but you get what you pay for,’’ Russ Childers, an Americus health insurance agent, told GHN on Wednesday. “It may not pay the benefit you think it might.”

Kaiser Family Foundation did a survey this year of current short-term plans and found that:

** 43 percent do not cover mental health services.

** 62 percent do not cover substance abuse treatment.

**  71 percent do not cover outpatient prescription drugs.

**  None cover maternity care.

“The administration’s rule change is dangerous for Georgia consumers,’’ said Laura Colbert of Georgians for a Healthy Future, a consumer advocacy group that supports the ACA. “Because many consumers shop for insurance based on premium price, these plans will look attractive but when consumers need to use their coverage, they may find that the services they need are not covered and they are left with large medical bills.



“The administration is irresponsibly condoning short-term plans as quality, affordable coverage and putting Georgians at risk,” Colbert said Wednesday.

The administration action comes at a time of increasing stability for Georgia’s health insurance exchange, created by the ACA.

Last month, the Georgia insurance department released proposed premiums for the state’s 2019 insurance exchange that ranged from about 2 percent to almost 15 percent. Those hikes are modest compared with the 2018 Georgia exchange hikes, which exceeded 50 percent for the four participating health plans.

The action on short-term plans is part of the administration’s and Republican lawmakers’ campaign to weaken the ACA. Next year, because of legislation passed in 2017, there will no longer be a tax penalty for someone who opts to not have insurance or who buys a short-term plan.

Short-term plans join “association health plans” for small businesses as the administration promotes lower-cost insurance options that cover less. Such plans can be offered across state lines and are also designed for self-employed people, The Associated Press reported.

Bill Custer, a health insurance expert at Georgia State University, said Wednesday that he sees “no other rationale’’ for pushing short-term health plans other than “undermining the ACA markets.”

These plans may attract healthier consumers who earn too high an income to receive a subsidy under the ACA exchanges, Custer said. Insurers offering these plans will have to balance a lower price with providing enough coverage to attract people, he said.

“They may market it to look better than what it is,’’ Custer added. “It’s going to be difficult for consumers to understand exactly what they’re buying.’’

The White House acknowledged these cheaper plans are not for everyone. “We make no representation that it’s equivalent coverage,” said Jim Parker, a senior adviser at the U.S. Department of Health and Human Services. “But what we do know is that there are individuals today who have been priced out of coverage.”

NFIB, a small-business advocacy organization, issued a statement that said “today’s final rule by HHS is another positive step for small-business owners that are seeking more affordable, flexible, and predictable options for themselves and their employees.”

But the American Hospital Association issued a statement Wednesday claiming that the new rule “will reintroduce, to an already shaky individual market, health plans that do not constitute true ‘insurance.’

“They could end up costing a patient far more by covering fewer benefits and ensuring fewer critical protections, like covering pre-existing conditions. Patients could find themselves responsible for their entire medical bill without any help from their ‘health plan.’

“For providers, these products will lead to increased bad debt, with underinsured patients unable to afford the care they need but that is not covered,’’ the AHA statement said.

The hospital organization added that these plans would remove younger, healthier people from the risk pool and driving up costs for those who remain.

By siphoning off younger or healthier consumers, the short-term plan expansion will add up to a 1.7 percent increase to premiums next year, according to the industry group America’s Health Insurance Plans, Kaiser Health News reported.

Insurance agent Childers agreed that more short-term plans may skim off healthier patients from the regular insurance market. “No one is buying them if they’ve been sick or have been sick,’’ he said.

Some in the industry say they’re developing “next generation” short-term plans that will be more responsive to consumer needs, with pros and cons clearly spelled out. Major insurer United Healthcare is marketing short-term plans, the AP reported.

The nonpartisan Congressional Budget Office estimates that roughly 6 million more people will eventually enroll in either an association plan or a short-term plan. The administration says it expects about 1.6 million people to pick a short-term when the plans are fully phased in, The AP reported.

Jan Dubauskas, general counsel for the IHC Group, an organization of insurance carriers headquartered in Stamford, Conn., told Kaiser Health News that she expects IHC to offer 12-month versions as soon as the rule goes into effect, which will be 60 days after it is published.

Georgia insurance department officials told GHN that they believe these short-term health plans “have served the public interest relatively well over the years, generally helping many consumers by bridging health coverage between employment-related group health insurance plans. Our experience with these products has never caused any patterns of consumer complaints regarding any of the relatively few insurers offering these short-term limited-duration products.”

The state officials said that they “are gratified to see that the former 3-month maximum duration federal rules have been stricken, and replaced by new rules.’’

The agency said it’s ready to assist any individual who has questions about insurance plans through its toll-free number in Georgia at (800) 656-2298 or through website


Fewer benefits. Riskier coverage. Buyer beware.

Good Pill helps provide affordable medication

The Good Pill drug donation and reuse program is now serving about 1,000 patients in the state, and the number has been growing by 40 percent a month since its formal launch in January. (Special Photo: Georgia Health News)

Good Pill is affiliated with a national nonprofit known as Sirum (Supporting Initiatives to Redistribute Unused Medicine), which was founded by students at Stanford University in California to help the uninsured and underinsured and others struggling to pay their prescription costs.

By Andy Miller. 

Georgia Health NewsPhoto-GoodPill.jpg

Medicare’s Hospital Outpatient Prospective Payment System Proposed Rule: Big Changes For 2019

JULY 27, 2018  On Wednesday, the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2019 hospital outpatient prospective payment system (OPPS) proposed rule addressing payments to hospital outpatient departments and ambulatory surgery centers (ASCs).

In the proposed rule, CMS made several significant proposals, including to expand a controversial policy that pays off-campus hospital departments at the same rate as physician clinics and to extend cuts for 340B-related drugs to such sites as well. Several proposals address the opioid epidemic, including un-packaging non-opioid pain medications in ASC surgical payments. CMS also requested input, while not formally proposing, a renewed Competitive Acquisition Program (CAP)-type model for purchasing Part B drugs through the Center for Medicare and Medicaid Innovation (CMMI).

Comments on the proposed rule are due by September 24 with a final rule expected by around November 1. 

Payment Rates

Overall, CMS estimates that outpatient hospital payments would decrease by a net of 0.1 percent ($80 million nationwide) relative to 2018 rates, which reflects a general market basket-based increase, then decreased by several adjustments, including for productivity, the off-campus policy described above, and a cut mandated by Congress.

Major teaching hospitals take the brunt of the hit, seeing an average decrease of 0.8 percent, while all other hospitals, on average, would see a 0.5% increase to payments.

For ASCs, citing comments received during the 2017 rulemaking cycle, CMS proposes to update rates based on the hospital market basket index instead of the consumer price index-urban (CPI-U) as it ordinarily does.

CMS estimates that ASC payments would increase by $32 million in CY 2019 compared to if they were based on the CPI-U approach. With all factors considered, ASC rates would increase by 2.0 percent in 2019, reflecting a 2.8 percent projected hospital market basket minus a 0.8 percent multi-factor productivity adjustment.

Expansion Of Site Neutrality For Outpatient Services

Section 603 of the Bipartisan Budget Act of 2015 (BBA) reduced payments to off-campus provider-based hospital departments to the amount paid to physician clinics for the same service, effective January 1, 2017. The BBA excepted certain sites from these payment reductions, namely those already billing under the hospital outpatient rate as of the date of enactment of the BBA (i.e., existing sites were grandfathered) and emergency services furnished by off-campus emergency departments.

In the proposed rule, CMS aims to extend this site neutrality policy beyond what is required by the BBA. It would cut payments to currently grandfathered sites for certain clinic visit services, citing concerns about the existing trend where more services are shifting away from doctor offices and into hospital outpatient departments. The proposal is not budget neutral, which is why it contributes to the net overall reduction in hospital payments that would be effectuated under the rule. According to the agency, about a fifth of the gross $760 million in savings from the proposal would accrue to patients in the form of reduced cost-sharing.

Further, CMS proposes to apply the site neutral payment policy to new lines of service added to previously st sharing exempted/grandfathered outpatient departments, positing that Congress would not have intended to allow such new families of service to be exempted from the BBA policy. The agency also notes that observed growth in new service lines at these outpatient facilities may have been an unintended consequence of the initial policy that it believes is best halted. 

New 340B-Related Cuts

Last year, CMS finalized a policy to pay covered outpatient drugs and biologicals acquired by hospitals under the 340B Program at a rate of average sales price (ASP) minus 22.5 percent, rather than ASP plus 6 percent that is typical under the payment system. This cut did not initially apply to off-campus hospital departments subject to the site neutrality policy described above, because the agency essentially now treats those sites like physician clinics.

 Here, CMS is now reversing that policy and would extend these cuts for 340B drugs to off-campus departments already facing payment cuts under the site neutrality policy. The agency would continue to exempt rural sole community hospitals, children’s hospitals, and certain cancer hospitals.

Opioid-Related Policies 

CMS proposes modifications to patient experience measures included in the hospital quality reporting program to remove three pain communication-related metrics. The change stems in part from concerns that providers may feel unduly pressured by patients seeking opioid-based therapies who can, in turn, report the physician neglected their preferences.

Further, citing the President’s Opioid Commission work, the agency adds new separate payment for non-opioid pain medications that otherwise function as a supply under the ASC payment system. It cites reports showing a 70 percent decline in such products after they lose pass-through status. CMS notes it is not applying the same change to hospital outpatient departments, suggesting that there is less evidence of behavioral change when pass-through status is removed in that setting.

RFI On Using Authority For Part B Competitive Acquisition Program Through CMMI

As signaled in the Administrations’ drug pricing Blueprint, CMS seeks comment on “key design considerations” for testing a CAP-like model through CMMI, citing comments submitted in response to a Request for Information (RFI) that accompanied the document.   

Specific questions are posed in four categories: 1) included providers and suppliers; 2) included drugs and biologicals; 3) beneficiary cost-sharing, 4) protections and fiscal considerations; 5) model vendors; 6) regulatory barriers and transparency issues; 7) manufacturer participation; and 8) model scope.

Initially established under the Medicare Modernization Act, the CAP program ultimately languished due to lack of provider or vendor participation. A pagereflecting the operation of the program is still available on CMS’s website.

Relatedly, CMS also seeks comment on how to promote interoperable electronic data exchange across providers and adds a new RFI on price transparency, including making charge information publicly available. 

There are several other policies in the proposed rule that I won’t address here but can be skimmed on the helpful fact sheet accompanying the release. Happy reg spelunking.


Meet the Rebate, the New Villain of High Drug Prices

A growing chorus, including the Trump administration, is calling for a rethinking of after-the-fact drug discounts that some say contribute to rising prices.

By Katie Thomas

  • July 27, 2018

An increasingly popular culprit in the debate over high drug prices is the pharmaceutical rebate, the after-the-fact discounts that form the heart of the nation’s arcane — many would say broken — market for prescription drugs.

Now, a growing chorus wants to get rid of them, or at least change the way they are applied after drug companies have already set their prices. Rebates, critics say, have pushed up the list price of brand-name drugs, which consumers are increasingly responsible for paying. Insurers generally get to keep the rebates without passing them along to their members.

Last week, the drug industry’s largest trade group, the Pharmaceutical Research and Manufacturers of America, took aim at the rebate system, proposing a change to the way middlemen handle rebates, and how those companies are paid.

And the Trump administration has taken the first step toward eliminating a “safe-harbor” provision that allows rebates to be paid in Medicare’s Part D drug program without violating federal anti-kickback laws.



The details, though sparse, briefly caused the fall of the stocks of major pharmacy benefit managers like Express Scripts and CVS Health as investors worried that company profits would be hurt by the rebate’s demise.

Here’s a rundown on everything you need to know about rebates.

What is a rebate?

Pharmaceutical rebates are similar to the type that you get when you buy a toaster — discounts that are redeemed after the transaction has taken place.

Except with the toaster, you get to keep the money. With drug rebates, it’s the insurer or employers who usually reap the benefit.

Under the current system, drug makers set a list price for their products, then negotiate with pharmacy benefit managers like Express Scripts or CVS over how much of a discount they will provide off that list price.

The size of the rebate depends on a range of factors, including how many drugs are used by the insurers’ members, and how generously the product will be covered on a formulary, or list of covered medicines. Companies that offer bigger rebates are often rewarded with better access like smaller co-payments.

Most of the rebate — and sometimes, all of it — goes to those who are paying the bill for the drugs, mainly insurers or large employers who cover their workers’ health care. Pharmacy benefit managers usually keep a percentage of the rebate as payment.

Insurers and employers get their rebates in lump sums that they say are often used to offset general health care costs and to hold down premiums.

What’s all the fuss about?

Although rebates have been used to negotiate drug prices for years, they didn’t catch much attention until 2011, when CVS, which operates one of the country’s largest pharmacy benefit managers, announced it was excluding 34 drugs from its national formulary.

The rebate then became a potent negotiating tool, pitting drug companies against each other in an effort to secure a place on the formulary. Other benefit managers, like Express Scripts, soon followed suit.

But that has led to an escalating game, where drug companies raise their list prices to maintain their profits and to offer bigger rebates.

Some say the system has created a series of perverse incentives, where the middlemen have an interest in keeping the list price high. In addition to pharmacy benefit managers, wholesalers and pharmacies are also paid based on a percentage of the list price.

Drug makers — on the defensive after weathering attacks by President Trump, other elected officials and the public — have pointed fingers at the pharmacy benefit managers, saying they are under pressure to raise list prices to keep all of these players happy.

But pharmacy benefit managers and insurers disagree, arguing that rebates are a diversion and that their negotiating tactics have kept total drug costs in check. As proof they point to data that shows that in 2017, net spending on brand-name drugs grew only 1.9 percent, according to IQVIA, a drug research firm, while list prices grew 6.9 percent.

In a twist, the pharmaceutical companies cite the same research to showthat drug prices are not as steep as they seem.

How are consumers affected?

Even as insurers’ drug spending has grown slowly, critics say the rebate game has served to inflate the list price of drugs, which consumers are increasingly responsible for paying. This is especially true for expensive specialty drugs, which treat serious conditions like cancer and multiple sclerosis — and whose prices have been skyrocketing.

As the cost of these products has gone up, insurers have raised deductibles and out-of-pocket contributions so that many of the sickest Americans must now pay thousands of dollars a year to cover their drug costs. These out-of-pocket costs are calculated using something close to the list price of a product, not the net price.


Many Americans are struggling to afford life-saving treatments for diseases like diabetes, multiple sclerosis, and cancer.

The Price They Pay

March 5, 2018

What’s being proposed?

Alex M. Azar II, the secretary of health and human services, has singled out rebates as a primary way that patients’ costs could fall.

“Right now, everybody in the system makes their money off a percentage of list prices,” Mr. Azar testified in June before a Senate committee. “We may need to move toward a system without rebates.”

Last week, the Trump administration signaled that it might try to end the “safe harbor” exemption that protects rebates from falling under anti-kickback laws. That would affect government programs like Medicare’s Part D drug plans, but it wouldn’t affect rebates in private plans — like those offered by employers. Changes to large programs like Medicare often have a rippling effect across the industry.

Pharmacy benefit managers and insurers warn that eliminating rebates could face legal hurdles, and said that the move could wind up raising consumers’ premiums because insurers and employers use their rebate payments to plug other holes.

“Plan costs in the short run would go up, that’s just the reality of the situation,” said David Dross, the national leader of the managed pharmacy practice at Mercer, which negotiates with pharmacy benefit managers on behalf of employers.

Doing away with rebates won’t fix other problems. The companies that sell the most expensive drugs — newly approved products that cost hundreds of thousands of dollars a year — don’t offer many discounts because they have little to no competition. IQVIA, the drug research firm, found that rebates amounted to about 40 percent of the list price for treatments of some diseases, like diabetes. But they reduced the list price by only 10 percent in treating other diseases, like cancer.

The Trump administration is also considering a proposal, first floated last fall, that would give a portion of rebates to Medicare beneficiaries at the pharmacy counter. The move would lower out-of-pocket costs for people with high drug bills, but could increase premiums for Medicare drug plans. Private insurers, like UnitedHealthcare, have also recently introduced plans that offer these “point-of-sale” rebates to some of their members.

How likely are rebates to disappear?

It’s unclear.

The drug industry, though it hasn’t specifically called for an end to rebates, has targeted the discounts and blamed the pharmacy benefit managers for the current situation. The industry is one of the most powerful lobbying forces in Washington, and with the support of Mr. Azar — until recently a top executive with Eli Lilly — they are not to be underestimated.

merlin_139865217_db8ae643-8dc3-4b74-b8a0-623ea9db516d-jumbo (1).jpg

We Need a Public Option for Prescription Drugs

Kara Eastman, the Democratic nominee in Nebraska’s Second Congressional District, tells a story while campaigning about visiting her mother while she was dying from cancer. Her mother’s medicals bills were stacked so high on the kitchen table, Eastman says, that when she visited, they couldn’t see each other through the piles. Just one of her mother’s pills cost $2,500 a month.

Eastman decided to run for Congress to offer alternatives to the skyrocketing cost of health care. She campaigns calling for Medicare for All and further solutions to the crisis of unaffordable prescription drugs. Her message is resonating. She beat a well-known opponent in her primary by a few hundred votes.

Spending on prescription drugs is growing faster than any other sector of our health-care system. Drug companies, meanwhile, are raking in record profits, far higher than those in other industries—and they are spending considerably more of it on buybacks and dividends than on research and development. Most importantly for their bottom line, they are breaking records with their spending to influence Congress to protect their monopolies.

Drug company revenues soared from $534 billion in 2006 to $775 billion in 2015. That’s billion with a “b.”

According to a study by researcher Adam Gaffney, Americans spend more on outpatient drugs than the residents of any other industrialized nation—$1,026 per capita annually. The average in advanced industrial nations is $515; in Denmark, it’s just $240. The problem isn’t that Americans use four times the drugs that Danes do; it’s that drug prices are much higher in the United States than anyplace else. In 2014, a daily 50-unit dose of insulin glargine cost $186 a month, after applicable discounts, in the United States—but only $63 in the United Kingdom and $46 in France.

In fact, U.S. taxpayers are paying twice. First, their taxes fund the research and development of new drugs: Federally funded studies contributed to the science behind every single one of the 210 drugs approved between 2010 and 2016. Taxpayers, for example, funded the development of Crestor, a popular medication to lower cholesterol. Now Crestor is sold by the private pharmaceutical giant AstraZeneca, which made over $16 billion in profits on Crestor alone during a three-year period.

It’s clear that simply strengthening regulations on pharmaceutical corporations is not enough. Such corporations will prioritize lining their pockets over saving the lives of everyone who needs their medications, when the laws permit that—as they do in the United States. And when they do invest, they will always invest where there is the greatest potential for profit, not where there is the greater potential benefit to the public health.

One way to address that dilemma is to create a taxpayer-owned drug company to produce and distribute medications at affordable prices—especially drugs that have been developed with U.S. taxpayer dollars. Unlike private corporations, this public drug company would focus on developing drugs based on public need rather than perceived profitability. The company could use private contractors to develop and manufacture the drugs, but it would own the patents and therefore ensure that everybody has access to them. Economist Dean Baker has pointed out that this type of model is how the Department of Defense operates to create many weapons of war.

The United States would not be the first country to create a national drug company. Brazil, Cuba, South Africa, and Sweden all have publicly owned drug companies. While there would be a cost to setting up a public drug company, Baker and others have shown that the savings on drug prices in the United States could fully offset the added costs of a such a company. Depending on the scope of that company, Baker has shown savings of hundreds of billions of dollars per year.

This is not just good policy. It’s good politics, too.

The Progressive Change Campaign Committee (co-founded by one of the authors) recently polled a cross-section of Republicans, independents, and Democrats in swing and Republican-leaning congressional districts on support for the idea of creating “a publicly-owned not-for-profit pharmaceutical company to compete against private drug companies, to create more competition in the marketplace and stop big drug companies from jacking up prices for our seniors.”

In the Third Congressional District in Kansas, currently represented by Republican Kevin Yoder, 61 percent said they support the idea, 23 percent are opposed, and 16 percent are not sure.

In the First Congressional District in Wisconsin, currently represented by Republican Speaker Paul Ryan, 69 percent support the idea, 20 percent oppose it, and 11 percent are not sure.

In the Third Congressional District of New Jersey, currently represented by Republican Tom McArthur (who introduced the bill that gutted much of the Affordable Care Act), 66 percent support the idea, 19 percent oppose it, and 14 percent are not sure.

These are overwhelming bipartisan numbers that reflect the impact that big pharma’s greed is having on Americans across the country. Families everywhere are struggling to absorb the skyrocketing cost of prescription drugs—drugs that were often developed with public money in the first place.

There is no good reason or justification for continuing with business as usual. We’re calling for a public drug company that allows us to keep life-saving technologies developed with our dollars in the public domain—and get them into the hands of everyone who needs them.

This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License


Prescription Drug Costs for Seniors

By Big Island Now

Posted August 3, 2017, 09:00 AM HSTUpdated August 3, 2017, 09:27 AM HST

Sens. Mazie K. Hirono and Amy Klobuchar (D-Minn.) introduced a bill to allow Medicare to negotiate the best possible price of prescription drugs to cut costs for nearly 41 million seniors enrolled in Medicare Part D.

Current law bars Medicare from bargaining directly with pharmaceutical companies.

“Our kūpuna deserve to have access to affordable prescription medication,” said Sen. Hirono. “This commonsense legislation allows Medicare to negotiate directly with manufacturers to bring down costs for Hawai‘i seniors and their families.”

The legislation would allow the Secretary of Health and Human Services to directly negotiate with drug companies for price discounts for the Medicare Prescription Drug Program, eliminating the “non-interference” clause that expressly bans Medicare from negotiating for the best possible prices.

With 41 million seniors, including nearly 70,000 in Hawai‘i, participating in Medicare Part D, Medicare could negotiate bigger discounts with pharmaceutical companies.

Sens. Chuck Schumer (D-NY), Patty Murray (D-WA), Tammy Baldwin (D-WI), Ron Wyden (D-OR), Richard Blumenthal (D-CT), Cory Booker (D-NJ), Sherrod Brown (D-OH), Tammy Duckworth (D-IL), Al Franken (D-MN), Kamala Harris (D-CA), Maggie Hassan (D-NH), Martin Heinrich (D-NM), Tim Kaine (D-VA), Angus King (I-ME), Patrick Leahy (D-VT), Claire McCaskill (D-MO), Chris Murphy (D-CT), Debbie Stabenow (D-MI), Ben Cardin (D-MD), Tom Udall (D-NM), Kirsten Gillibrand (D-NY), Michael Bennet (D-CO), Maria Cantwell (D-WA), Joe Manchin (D-WV), Jeff Merkley (D-OR), Bill Nelson (D-FL), Jeanne Shaheen (D-NH), Chris Van Hollen (D-MD), Mark Warner (D-VA), and Elizabeth Warren (D-MA) are also cosponsors of the legislation.

Kaine, Warner Move to Drop Prescription Drug Costs

AUGUST 2, 2017 9:49 PM0 COMMENTS


Virginia’s U.S. Senators Mark Warner and Tim Kaine joined U.S. Senator Amy Klobuchar (D-Minn.) and 29 of their colleagues to introduce legislation to lower prescription drug costs this week. The bill would allow for Medicare to negotiate the best possible price of prescription drugs to cut costs for nearly 41 million seniors enrolled in Medicare Part D. Current law only allows for bargaining by pharmaceutical companies and bans Medicare from doing so.

The legislation would permit the Secretary of Health and Human Services to directly negotiate with drug companies for price discounts for the Medicare Prescription Drug Program, eliminating the “non-interference” clause that expressly bans Medicare from negotiating for the best possible prices.


Udall, Heinrich Cosponsor Bill To Allow Medicare To Negotiate A Better Deal On Prescription Drug Costs

Udall, Heinrich Cosponsor Bill To Allow Medicare To Negotiate A Better Deal On Prescription Drug Costs

Submitted by Chris Clark 

on August 3, 2017 - 7:19am


WASHINGTON, D.C. ― Yesterday, U.S. Senators Tom Udall and Martin Heinrich joined in cosponsoring legislation led by U.S. Sen. Amy Klobuchar (D-Minn.) to unleash the bargaining power of seniors for a better deal on prescription drug costs.


The legislation would allow for Medicare to negotiate the best possible price of prescription drugs to cut costs for nearly 41 million seniors enrolled in Medicare Part D. Current law prevents Medicare from directly negotiating for lower drug prices, a practice regularly used to bring down prescription drug costs for the Veterans Administration. In New Mexico, there are over 150,000 seniors enrolled in Medicare Part D.


“This bill will enable New Mexico seniors to get a better deal on the prescription drugs they need to stay healthy,” Udall said. “I’m committed to working to find common-sense solutions, like this legislation, to lower the price of life-saving prescription drugs for New Mexicans and people across the United States.”


“When it comes to the soaring costs of prescription drugs for seniors, there’s nothing more effective that we could do then to allow Medicare to negotiate lower drug prices,” Heinrich said. “Changing the law so Medicare is no longer banned from negotiating the best possible price of prescription drugs for seniors is a no-brainer. Older New Mexicans struggling to afford the medication they are prescribed deserve better.”


The legislation would allow the Secretary of Health and Human Services to directly negotiate with drug companies for price discounts for the Medicare Prescription Drug Program, eliminating the “non-interference” clause that expressly bans Medicare from negotiating for the best possible prices. By harnessing the bargaining power of nearly 41 million seniors, Medicare could negotiate bigger discounts with the pharmaceutical companies.


A copy of the bill is available here

Tampa Bay residents say Obamacare repeal would threaten lives and livelihoods


Richard Danielson, Times Staff Writer
TAMPA — A St. Petersburg woman who couldn't get insurance while a sinus tumor and associated infections ruined her health for three years.

A Sarasota woman born without arms who could lose health care and prescription coverage for autoimmune disorders that developed after she was seriously hurt in a car crash.

A Sun City Center business owner whose breast cancer treatments were paid for by Obamacare.

A South Tampa family whose disabled son can be cared for at home thanks to Medicaid, instead of in a hospital, despite living with a tracheotomy.

Each said Monday that their lives could be torn apart by Republican proposals to repeal the Affordable Care Act and reduce projected Medicaid spending by $800 billion over a decade.

"The ACA saved my life," Gina Hebert said during a roundtable health care discussion organized by Florida Democratic Sen. Bill Nelson.

Hebert, 60, had pre-existing conditions including severe arthritis and kidney stones when she received coverage through the ACA health care exchanges and started her own business as a construction estimator.

"When the ACA came up, I grabbed hold of that insurance policy first thing," said Hebert, who said she does not receive any government support to pay the premiums.

Having the insurance became especially critical, she said, when she was later diagnosed with Stage 2 breast cancer. She had two surgeries, months of chemotherapy, months of radiation and has been cancer-free for two years.

"The ACA saved my life," Hebert said. "If the cancer comes back and I don't have insurance" she would have to face going bankrupt and closing her business, "which means I'm not paying taxes, which means I'm not contributing to society."

The nonpartisan Congressional Budget Office predicts passage of the U.S. Senate's proposed health care bill would leave 22 million additional Americans without health insurance.

"If they repeal it, there is no insurance company that's going to insure me," said Olivia Babis, 40, who does not have arms and works as a peer mentor for other people with disabilities at a center for independent living. "I have two autoimmune disorders. My prescriptions are $200 a month. Without insurance, there's no way I can afford that."

Coverage losses are projected to especially affect people ages 50 to 64, before they qualify for Medicare, who earn less than about $30,300 for a single person.

Meanwhile, the budget office said, the Senate bill would eliminate two taxes aimed at wealthy Americans and levies on the medical-related industry, giving those groups savings of more than $540 billion.

It also would allow states to ease Obamacare requirements that insurers have to pay for certain specified services, including substance abuse treatments.

Nelson, who served as Florida's elected insurance commissioner, said he has seen health insurance companies deny coverage based on pre-existing conditions like asthma, but also something as simple as a rash.

He also said he's seen companies dedicate 60 percent of the revenue from premiums to health care, while spending 40 percent on administration and overhead. Under the Affordable Care Act, Nelson said, administrative costs are capped at 20 percent.

Still, he said, "The ACA is not perfect, and there are a bunch of things we ought to fix."

For example, he said, Affordable Care Act premiums could be reduced 13 percent in Florida if Congress changed the law to require insurance companies to buy re-insurance to cover the costs of catastrophic cases that cost millions of dollars.

Congress also could lower the price of some prescription drugs by continuing to use discounted Medicaid prices once patients with Medicaid turn 65 and go on Medicare, which pays more for the same drugs.

"There are fixes that we could do," Nelson said, "if we could ever get together."

Contact Richard Danielson at or (813) 226-3403. Follow @Danielson_Times

Tampa Bay residents say Obamacare repeal would threaten lives and livelihoods 07/03/17 [Last modified: Monday, July 3, 2017 10:31pm] 

The New War on (Overpriced) Drugs


UNLESS YOU HAVE multiple myeloma, a rare and vicious cancer of the blood, chances are you haven’t heard of Revlimid. The immunomodulatory drug slows the growth of new blood vessels, and it’s a product of the kind of ingenuity and daring that once made the pharmaceutical industry among the most respected in America. It’s also a handy stand-in for everything that’s wrong with the business today.

In the early 1990s, researchers at Boston Children’s Hospital stumbled on an old sedative that appeared to slow the progress of myeloma. The drug, thalidomide, was infamous. It had been prescribed widely for morning sickness in the 1950s, but caused thousands of horrific birth defects. Still, nothing had ever been as effective against multiple myeloma, so a biotechnology company called Celgene took a risk and spent millions of dollars developing an analogue of the compound, transforming thalidomide into a more potent cancer drug.

It worked: When the FDA approved Revlimid to treat meyloma in 2006, it revolutionized the cancer's treatment. Average survival time jumped from three or four years in the late ’90s to almost a decade today. “There’s not one other disease where you can say we tripled survival in that period of time,” says Mohamad Hussein, Celgene’s head of scientific affairs. Through calculated risk and dedicated bench work, Celgene had turned poison into gold.

The story of Revlimid’s development is unique, even uplifting. But the story of what it costs is all too familiar. In the past decade, the drug’s price jumped from $78,000 a year to $156,000. Last year, the median myeloma patient on Medicare—a person supposedly shielded from extortionate drug prices—paid $11,538 out of pocket each year for the medication. (A majority of American families have less than $5,000 in savings.)

Revlimid has produced at least $20 billion in revenues since its release, but Celgene, and all pharmaceutical companies, say they need high prices to continue developing lifesaving medications. “You get what you pay for,” Hussein says.

The 25-milligram pill encapsulates everything that’s great and everything that’s terrible about the US pharmaceutical industry. In the past five years, the price of brand-name prescription drugs has doubled; cancer drugs, specifically, have gone up by a multiple of six since 2000.

Several promising new myeloma drugs have recently been released, including a new and improved follow-up treatment to Revlimid called Pomalyst. Each drug costs more than $150,000, and Pomalyst comes in over $195,000. “This is not a sustainable model,” says Brian Bolwell, chairman of the Taussig Cancer Institute at the Cleveland Clinic.

Many doctors and patients across the country would agree. So, at a moment when Congress and the Trump administration are grappling with revamping the entire health care economy, we should ask ourselves: How much should a drug actually cost, anyway?


It’s a strangely subversive question and one that Steve Pearson, an unassuming internist turned Harvard lecturer turned nonprofit chief, thinks he can answer. Pearson is one of the few people in this country who’ve had any luck getting the prices for individual drugs under control. The nonprofit he founded, the Institute for Clinical and Economic Review (known as ICER), has one purpose—to figure out whether a new drug is worth the price tag or if Big Pharma is taking us for a ride.

For the most part, Pearson says, Americans have no idea what they should be paying for medication. We don’t how much it costs to actually develop a drug; the FDA doesn’t require comparative effectiveness studies, so we don’t know if new drugs work better than existing competitors; and we have little information about how much other consumers are paying for the same products. “Patients in America are getting great value for drugs—and we're getting ripped off,” Pearson says. “The problem is we’ve had little way of knowing when it's one or the other.”

President Donald Trump has said that the pharmaceutical industry is “getting away with murder” and that he wants to let Medicare negotiate with drug companies over the prices we pay—something that was forbidden in 2003, part of a compromise with the politically potent industry to get the Medicare drug expansion plan passed. (Since 1998, Big Pharma has spent more on lobbying than any other industry.)

In The Art of the Deal, Trump says that you have to “know when to walk away from the table.” But Medicare—which covers some 57 million people—essentially can’t decline any drug the FDA approves, at least for serious diseases like cancer. It can’t walk away from the table. Furthermore, the agency doesn’t have any more comparative data than you or I do. When one party in a deal knows more about the goods than the other, economists call itinformation asymmetry. It’s a classic recipe for market failure and, as any seasoned negotiator knows, a great way to get a bad deal.

Pearson, with ICER, has taken it upon himself to fix this information imbalance, to generate the missing data and calculate a “fair price” for drugs. The team’s efforts involve a forensic approach to dozens of scientific studies and a Vulcan-eyed look at how we value human life and decide to allocate resources. It is straightforward yet radical work—a missing puzzle piece in the effort to solve our drug-pricing crisis.

The Centers for Medicare and Medicaid Services recognized this last spring, when they floated the idea of using ICER’s calculations if Congress ever let them negotiate prices. Pharma-backed groups acknowledged this when they launched a blitz to discredit the group last year. And so far, Pearson’s method has successfully checked the prices of a handful of drugs—something very few people can say they’ve done.

But as sensible as the exercise may look in a PowerPoint presentation, some of the people Pearson is trying to help aren’t buying in. “The new drugs are awesome,” says Matt Goldman, a myeloma patient in Long Beach, California, but if ICER were to decide his meds are overpriced, “our insurance company is going to read this and they’re going to start denying benefits—these are life and death decisions.”

Nick Van Dyk, a patient who credits Revlimid with keeping him alive, is more succinct. “I’m talking to you instead of pushing up dirt because of Big Pharma,” he says. “The ICER guy is a smug, rotten scumbag.”

Cold-Blooded Math

Figuring out if a drug is priced fairly is not a simple process. One of the first things you have to do is put a value on human life.

Kind of. A quality-adjusted life year, or QALY (pronounced “kwaly”), is the metric that health economists use to measure the value of medical treatments over time. One QALY is a year of perfect health thanks to a med; zero QALYs means you’re dead. Three extra months of life in great health, Pearson says, gets a higher QALY value than three months with terrible side effects.

So what’s a year of feeling healthy worth? Based on data from the World Health Organization and other sources, ICER puts the value of a quality-adjusted life year in the United States at between $100,000 and $150,000. (If it unnerves you that the health care system has decided a year of your health is worth the price of a tacky speedboat, know that QALYs are used everywhere life is taken into consideration; the Department of Transportation uses them when it decides how much it should spend on expensive safety features, like extra lanes or guardrails along freeways.)

Any drug that provides significant health benefits at under $100,000 per QALY is golden and ICER rates it as “high value.” Ones that cost more than $150,000 per QALY get “low value” or, at best, “intermediate value” if the drug provides a legitimate benefit to patients.

Cold-blooded as they may be, QALYs aren’t controversial for health economists, but the very idea of quantifying life upsets plenty of people—the approach carries a whiff of “death panels,” after all. Still, Pearson says, controversy is no reason to shy away from a useful metric. “The QALY just helps us compare apples to apples when we want to consider the gains we make with good new treatments,” he says.

For Pearson, paying too much for drugs matters not just because pharmaceuticals eat up a growing chunk of our total health spending—17 percent at last check—but because the money we spend on overpriced pills is money we could spend better somewhere else. “Health is a very important—perhaps the most important goal for us as individuals, and for our society,” Pearson says. “But it’s not the only goal. We also want good jobs, great schools, a safe environment.”

The money you spend on overpriced drugs, he argues, is money that doesn’t go to your kid’s school or the ambulance driver or fire department. “There are choices within the health care system: Should we get this machine or pay another doctor?” he says. “Then, step back and it’s: Another hospital or 10,000 more teachers?”

Pearson’s office in ICER’s downtown Boston headquarters is spare and unlived-in when we meet in August. He spends most of his time in DC; his family lives there, and he’s a visiting scientist at the National Institutes of Health. But Boston is ICER’s home, he says, across the river from Harvard, where Pearson is a lecturer and where he founded the institute back in 2007.

In conversation, Pearson is even-keeled and reassuring—like a doctor walking you through a mixed prognosis. Goateed and with tortoiseshell, geek-chic glasses, he’s wearing cufflinks embossed with the crest of the Royal College of Physicians, where he’s an honorary fellow. (His CV is a grab bag of elite institutions and includes a Stanford undergraduate degree, a master’s from Harvard, and an MD from UC San Francisco.) With his staff of 24 doctors and policy wonks, he aims to put out about nine reports a year, covering dozens of treatments.

A Media Matters review of weekday evening news coverage on cable and broadcast networks since December reveals that the evening programs largely ignored the problem of escalating prescription drug prices in the United States, even though lawmakers have introduced legislation aimed to address the issue. 

Democrats Introduced A New Bill To Fight Escalating Prescription Drug Costs In The U.S.

The Hill: Sanders First Introduced Amendment Allowing Prescription Imports Last December. The Hill reported on December 6 that Sen. Bernie Sanders (I-VT) had introduced an amendment to the 21st Century Cures Act that would have allowed prescription drug imports from other countries while also allowing Medicare to negotiate directly with drug companies for lower prices. Republicans in the Senate blocked the amendment, which Sanders framed as a way to fulfill then President-elect Donald Trump’s promise to help lower drug prices. [The Hill12/6/16]

Wash. Post: Democrats Introduced A Bill “To Allow Commercial Importation Of Drugs From Canada.” The Washington Post reported last month that Sanders “and a slew of Democratic colleagues” introduced a prescription drug bill in the Senate “to allow commercial importation of drugs from Canada,” where they often cost substantially less than American pharmaceuticals do. The article noted that “through cheap imported drugs, the United States would be able to take advantage of the government levers and regulation that other countries have used to bring down pharmaceutical prices.” From the February 28 article:

Opening a new front in the war against big pharma, Sen. Bernie Sanders (I-Vt.) and a slew of Democratic colleagues introduced a bill Tuesday to allow commercial importation of drugs from Canada.

The appeal is obvious; through cheap imported drugs, the United States would be able to take advantage of the government levers and regulation that other countries have used to bring down pharmaceutical prices. It's a far more politically palatable way to attack the problem of soaring drug prices than opening up an even more contentious fight over whether the U.S. government should meddle directly in pricing — and it has had wide popular and bipartisan support, including from Hillary Clinton and Donald Trump during the presidential campaign.


In an afternoon news conference unveiling the bill, Democratic and independent lawmakers threw down the gauntlet, calling on President Trump — who has repeatedly said that he will do something to rein in rising drug prices — to support their effort.

“I want to finally say about our president, who has said a lot of talk about health care and has recently confessed how 'complicated’ he thinks it is. He has made promises to the American people about prescription drug prices; he has made promises to the American people, and now it's time for him to put up or shut up,” said Sen. Cory Booker (D-N.J.), who joined as a co-sponsor after voting against drug importation when it was an amendment. “It’s time for him to join with us, or, in my opinion, to confess his lies to the American people.” [The Washington Post2/28/17]

By Susan Jones | March 27, 2017 | 7:29 AM EDT



Sen. Bernie Sanders (I-Vermont) says he will introduce a single-payer, Medicare for all bill. He appeared on CNN's "State of the Union" on Sunday, March 26, 2017. (Screen grab from CNN)

( – The Republican repeal and replace bill was a “disastrous piece of legislation” designed to give tax breaks to the wealthy, and it deserved to die in the House, Sen. Bernie Sanders, a Vermont socialist, told CNN’s “State of the Union” on Sunday.

He also admitted that the Democrats’ Obamacare has “serious problems,” including premiums and deductibles that are too high and areas of the country where people don’t have a choice of insurance plans.

“Ideally, where we should going is to join the rest of the industrialized the world and guarantee health care to all people as a right. And that's why I'm going to introduce a Medicare-for-all single-payer program,” Sanders said.




Sanders wants to give people in every state a “public options from which they can choose. Let's talk about lowering the age of Medicare eligibility from 65 to 55. Let's deal with the greed of the pharmaceutical industry.

“Those are areas that we can work together on,” Sanders said, ignoring the fact that Republicans will not back a government-run option.


Sanders: ‘I'm Going to Introduce a Medicare-for-All, Single-Payer Program’

By Susan Jones | March 27, 2017 | 7:29 AM EDT


Sen. Bernie Sanders (I-Vermont) says he will introduce a single-payer, Medicare for all bill. He appeared on CNN's "State of the Union" on Sunday, March 26, 2017. (Screen grab from CNN)

( – The Republican repeal and replace bill was a “disastrous piece of legislation” designed to give tax breaks to the wealthy, and it deserved to die in the House, Sen. Bernie Sanders, a Vermont socialist, told CNN’s “State of the Union” on Sunday.

He also admitted that the Democrats’ Obamacare has “serious problems,” including premiums and deductibles that are too high and areas of the country where people don’t have a choice of insurance plans.

“Ideally, where we should going is to join the rest of the industrialized the world and guarantee health care to all people as a right. And that's why I'm going to introduce a Medicare-for-all single-payer program,” Sanders said.




Sanders wants to give people in every state a “public options from which they can choose. Let's talk about lowering the age of Medicare eligibility from 65 to 55. Let's deal with the greed of the pharmaceutical industry.

“Those are areas that we can work together on,” Sanders said, ignoring the fact that Republicans will not back a government-run option.





The ABCs of picking a Medicare Supplemental Policy

Jim Miller, Savvy Senior4:05 p.m. MT March 5, 2017


(Photo: DVT)


Dear Savvy Senior: Can you provide any advice on choosing a Medicare supplemental policy to help cover things outside of Medicare? I’ll be 65 in a few months and could use some assistance. — Looking for Help

Dear Looking: If you plan to enroll in original Medicare, getting a supplemental policy (also known as Medigap insurance) too is a smart idea because it will help pay for things that aren’t covered by Medicare like copayments, coinsurance and deductibles. Here are some tips to help you choose an appropriate plan.

Medigap Plans                                                                  

In all but three states (Massachusetts, Minnesota, and Wisconsin), Medigap plans, which are sold by private health insurers, come in 10 standardized benefit packages labeled with the letters A, B, C, D, F, G, K, L, M and N.

Plan F is the most popular policy followed by plan C because they provide comprehensive coverage. Plans K and L are high-deductible policies that have lower premiums but impose higher out-of-pocket costs. Plan F also offers a high-deductible version in some states. And a popular middle ground policy that attracts many healthy beneficiaries is plan N.

For more information on the different types of plans and the coverage they provide, including Medigap options in Massachusetts, Minnesota, and Wisconsin, see Medicare’s “Choosing a Medigap Policy” guide at, or call 1-800-MEDICARE and ask them to mail you a copy.

How to Choose

To pick a Medigap policy that works best for you, consider your health, family medical history and your budget. The differences among plans can be small and rather confusing.

To help you choose, visit, and click on “Supplements & Other Insurance” at the top of the page, then on “Find a Medigap policy” and type in your ZIP code. This will give you a list of the plans available in your area, their price ranges and the names, and contact information of companies that sell them. But it’s up to you to contact the carriers directly to get there specific pricing information.

You can also compare Medigap prices on most state insurance department websites (see for links), or you can order a personalized report from Weiss Ratings for $99 at

Since all Medigap policies with the same letter must cover the exact same benefits (it’s required by law), you should shop for the cheapest policy.

You’ll get the best price if you sign up within six months after enrolling in Medicare Part B. During this open-enrollment period, an insurer cannot refuse to sell you a policy or charge you more because of your health.

You also need to be aware of the pricing methods, which will affect your costs. Medigap policies are usually sold as either: “community-rated” where everyone in an area is charged the same premium regardless of age; “issue-age-rated” that is based on your age when you buy the policy, but will only increase due to inflation, not age; and“attained-age-rated,” that starts premiums low but increases as you age. Community-rate and issue-age-rated policies are the best options because they will save you money in the long run.   

You can buy the plan directly from an insurance company, or you can work with a reputable local insurance broker.

Drug Coverage

You also need to know that Medigap policies do not cover prescription drugs, so if you don’t have drug coverage, you need to consider buying a separate Medicare Part D drug plan too. See to compare plans. Also note that Medigap plans do not cover vision, dental care, hearing aids or long-term care either.

Alternative Option

Instead of getting original Medicare, plus a Medigap policy and a separate Part D drug plan, you could sign up for a Medicare Advantage plan that provides all-in-one coverage. These plans, which are sold by insurance companies, are generally available through HMOs and PPOs. To find and compare Advantage plans visit

Send your senior questions to: Savvy Senior, P.O. Box 5443, Norman, Okla. 73070, or visit Jim Miller is a contributor to the NBC Today show and author of “The Savvy Senior” book.


Motley Fool on Medigap Plans.

There are a variety of Medigap plans, and while any one of them will add an additional expense to your retirement budget, they can be well worth it for the peace of mind they provide.

Matthew Frankel


Feb 12, 2017 at 7:07AM

One decision people need to make when they reach age 65 is whether to enroll in a Medicare Supplemental Insurance -- aka, a Medigap plan -- to help cover the healthcare costs that Medicare doesn't. Here's what you need to know about how much you can expect Medicare to cover, and the various Medigap options available.

How much will healthcare cost you after age 65?

Once you reach 65, you'll probably be covered by Medicare Parts A and B, which are hospital and medical insurance, respectively, and are collectively referred to as "original Medicare." Medicare Part A is free for most people, but you'll pay a premium for your Part B coverage; it's currently $109 per month for the majority of Medicare beneficiaries. In addition, there are several expenses you can expect to pay for out-of-pocket, such as dental care, eyeglasses, and of course, your copays.



However, it's important to recognize that these costs can vary significantly from person to person. For example, if you have congestive heart failure, you can expect nearly $4,000 added to your annual out-of-pocket expenses. In a Kaiser Family Foundation study, it was determined that the average Medicare beneficiary in poor health had about 2.5 times the out-of-pocket expenses of people in excellent health. Since it's impossible to know when your health might go from good to not-so-good, it's reasonable to assume that your actual out-of-pocket healthcare expenses in retirement will be unpredictable if you have only original Medicare.

What do Medigap plans cover, and how much do they cost?

Medigap plans are standardized, and must be clearly identified as "Medicare Supplement Insurance." In most states (Massachusetts, Minnesota, and Wisconsin are the exceptions), Medigap policies are identified by one of 10 letters.

Each of these 10 plan types provides a different package of benefits. Some cover copays and coinsurance, and some cover Medicare's deductibles, either in full or in part. For example, Medigap Plan A is required to be offered by any insurance company that sells Medigap policies, and pays for things like Medicare Part A and B coinsurance and copayments in full, but does not cover the Part A and B deductibles. You can compare what each plan covers on Medicare's website.

Medigap Plan F is the most comprehensive and covers virtually every copay and deductible you could face. While it's the most expensive plan, it's also the most popular by far, chosen by two-thirds of seniors who decide to buy a Medigap plan. It seems seniors are willing to pay for the peace of mind of not having to worry about healthcare costs.

Availability of Medigap plans varies by location and insurance company. As I mentioned, all insurance companies that offer Medigap plans must offer plan A. In addition, they must offer either plan C or F. Beyond that, the exact assortment of plans offered by each insurer can vary significantly. Costs also vary significantly, depending on your location and the plan you choose. For example, the most popular and comprehensive Medigap plan, plan F, has a national average monthly premium range from $159 to $239 per month for a 65-year-old male.

You can compare your options by using's plan finder. If you have two addresses, such as a summer and winter home, it's a smart idea to compare the costs at both.

Should you get a Medigap plan?

Whether or not you should get a Medigap plan depends on how much risk you're willing to take with your healthcare costs in retirement. Medicare parts A and B cover a great deal, but don't cover everything. And, there is no out-of-pocket maximum. A serious illness could potentially cost you a tremendous amount of money if original Medicare is the only insurance you have.

While it is an additional expense to worry about, a Medigap plan can help you define your healthcare expenses more precisely, and set an upper limit on your medical costs in retirement.


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Americans Like Obamacare. They Just Don’t Know It


"Just because you need to do the top floor doesn't mean you level the entire complex." 


Although his signature law is in jeopardy, President Barack Obama's work reshaping health care in America is certain to endure in the broad public support for many of its underlying principles, along with conflicts over how to secure them.

The belief that people with medical problems should be able to get health insurance is no longer challenged. The issue seems to be how to guarantee that. The idea that government should help those who can't afford their premiums has gained acceptance. The question is how much, and for what kind of coverage.


A sign is held up that reads "ACA Is Here To Stay" front of the US Supreme Court after a 2015 ruling in favor of the Affordable Care Act. Mark Wilson / Getty Images

"The American people have now set new standards for access to health care based on the Affordable Care Act," former Surgeon General Dr. David Satcher says. "I don't believe it will ever be acceptable again to have 50 million people without access to health care."

Obama's influence will continue in other ways, less visible and hardly divisive:

  • Medicare is shifting to paying for value, not just volume.
  • The importance of prevention and front-line primary care is more widely recognized.
  • Doctors and hospitals have computerized their records systems, even if connectivity remains elusive.
  • The government has opened up mass files of health care billing data, enabling independent analysts to look for patterns of questionable spending.

But conflict is part of Obama's legacy, too. He leaves the country deeply divided about the government's role in health care.

Related: Will Obamacare Repeal Cost Millions of Jobs?

Passed with no Republican votes, the 2010 health care law broke the pattern of major safety net programs like Social Security, Medicare and Medicaid, which had bipartisan backing. Social Security has stood for more than 80 years; Medicare and Medicaid for more than 50.

"If Medicare had been repealed, stories about Lyndon Johnson would have been different," said Robert Blendon, professor of health policy at the Harvard T.H. Chan School of Public Health. "A legacy is whether you did something that was sustained." Johnson was the Democratic president who won approval of Medicare and Medicaid in 1965.

Already, the Republican-led Congress, taking its lead from President-elect Donald Trump, has started the process of repealing and replacing the health law.

“I really do credit Obamacare with saving my life.”

"Approaches that partisan are difficult to sustain as lasting, permanent features of the health care system," said Mark McClellan, Medicare administrator under Republican President George W. Bush.

Obama also failed to deliver on early promises to cut premiums. From 2009-2016, the amount employees pay in premiums for workplace coverage rose by hundreds of dollars, according to the nonpartisan Kaiser Family Foundation. And the average deductible — the annual amount patients pay before insurance kicks in — went from $533 to $1,221, an increase of nearly 130 percent.

Related: Five Things You May Not Know About Obamacare

The achievements and difficulties of the Obama years are reflected in people such as Karen Rezny.

"I really do credit Obamacare with saving my life," said Rezny, a massage therapist from Austin, Texas.

The health care law, or ACA, enabled her to get better treatment for advanced breast cancer. She was uninsured when diagnosed. Before the law, insurers would have rejected her because of her pre-existing medical condition. Even with a subsidized premium, Rezny said she still struggles with cost.

"What I would hope is that we would look back and say (Obama) got the ball rolling, and then we continue," said Rezny. "He took health care off the House and Senate floor — out of theoretical talk by people who are guaranteed lifetime health care — and actually allowed the people to experience it and have it."

When the law passed, 48.6 million people were uninsured, according to the government. Through the first six months of last year, that dropped to 28.4 million. While employer coverage also grew as the economy strengthened, experts credit the ACA for most of the progress. The law provides subsidized private insurance along with a Medicaid expansion for low-income people.

"It would have never been done without the focus and insistence of this president that we go big," said Kathleen Sebelius, Obama's first secretary of Health and Human Services.

Obama set his sights high, but execution was a problem. When went live in 2013, the computer system quickly froze. It took a high-tech rescue effort to get things working for consumers.

“Just because you need to do the top floor doesn’t mean you level the entire complex.”

The law's complexity also tripped people up. It uses the income tax system to subsidize premiums. Some customers saw their tax refunds reduced because they underestimated their incomes when applying for subsidies. Fines on those who remained uninsured hit people in their 30s trying to get traction in life. Officials in many states were alarmed by rising Medicaid spending.

When Republicans won control of the House in 2010, Obama was effectively blocked from legislating fixes. The administration used regulations to try smooth out the law's rough edges, while successfully fighting off two Supreme Court cases that would have gutted it.

Related: Obamacare Premiums Are Going Up

In the face of problems, the White House ceaselessly talked up the benefits of the law. Among the controversial claims was that the law deserved much credit for a historic slowdown in national health care spending from 2009-2013.

"Just nonsense," said Rick Foster, formerly Medicare's chief actuary, in charge of long-range estimates. "Far and away the biggest cause of the slowdown was the Great Recession. That is not to say that the Affordable Care Act didn't have some impact, but I think that was small compared to the effect of the recession and the weak recovery."

History shows that America's social programs got built in stages. Automatic cost-of-living increases weren't part of Social Security originally. Medicare didn't get a prescription benefit for nearly 40 years.

Kris Case of Denver hopes that somehow, something like that can happen with Obama's overhaul. She works in customer relations for a technology company and buys coverage through the Colorado insurance marketplace.

"Think of all the work that has gone into this imperfect thing," said Case, "and to just tear it down to make a point, rather than say it's flawed but we can fix it.

"Just because you need to do the top floor doesn't mean you level the entire complex." 

6.4M Have Signed Up So Far for Obamacare, Ahead of '15 Pace

WASHINGTON —   December 21, 2016 7:47 PM Associated Press

Obamacare seems to be holding its own. The administration said Wednesday that 6.4 million people had enrolled for subsidized private coverage through in this year's sign-up period, ahead of last year's pace.

Despite rising premiums, dwindling insurers and the Republican vow to repeal President Barack Obama's health care law, about 400,000 more people signed up through Monday than was the case for a comparable period in 2015, the Health and Human Services Department said.

"Today's enrollment numbers confirm that doomsday predictions about the marketplace are not bearing out," said HHS Secretary Sylvia Burwell.

FILE - Health and Human Services Secretary Sylvia Burwell speaks during a news conference at the HHS in Washington, Oct. 19, 2016. The Obama administration says 6.4 million people have signed up so far this year for subsidized private insurance coverage through

Still, it's too early for supporters of the Affordable Care Act, or ACA, to say, "I told you so."

It's unclear whether the administration will meet its target of 13.8 million sign-ups. That's partly because the share of new customers is down when compared with current consumers re-upping for another year.

New customers are 32 percent of the total this year versus 40 percent around the same time last year. Administration officials said they're going to focus on getting more new customers between now and the end of open enrollment January 31.

No signs of 'collapse'

Other vital signs for were encouraging.

"There are zero signs that the ACA's marketplaces are in danger of imminent collapse," said Larry Levitt of the nonpartisan Kaiser Family Foundation, who has followed the health care law from its inception.

That carries an implicit warning for President-elect Donald Trump and congressional Republicans, who have promised to move quickly to repeal the law. That repeal would be followed by a GOP-inspired replacement. Although immediate changes affecting 2017 are unlikely, the whole process could take several years, creating uncertainty for people with coverage.

As if on cue, Democratic governors Wednesday fired off a letter to GOP congressional leaders, calling the repeal plan "nothing more than a Washington, D.C., bait-and-switch" that would leave millions uninsured and shift to states an estimated $69 billion in uncompensated care costs over a decade.

The statistics released Wednesday are for 39 states served by the federal online insurance marketplace. Numbers from states running their own markets have not been fully tallied and will be added later, raising the total. Toward the end of this month, several million current customers who are being re-enrolled automatically will be added to the count.

Red state sign-ups

Some of the biggest sign-up numbers so far are coming from states Trump won in the presidential election, including Florida (1.3 million); Texas (776,000); North Carolina (369,000); Georgia (352,000) and Pennsylvania (291,000). Vice President-elect Mike Pence's home state of Indiana had 119,000 residents enrolled.

Premiums for a midlevel benchmark plan in states are going up an average of 25 percent next year, driven by lower-than-expected enrollment and higher medical costs. At the same time, about one-third of U.S. counties will have only one marketplace insurer next year because some major commercial carriers have left the market, and many nonprofit insurance co-ops created by the law have collapsed.

The impact of premium increases has been softened by the law's subsidies, which are designed to rise if the cost of insurance goes up.

A study last week from the nonpartisan Center for Health and Economy found that the average monthly subsidy will increase by $76, or 26 percent, from $291 currently to $367 in 2017.

But that means taxpayers will fork over nearly $10 billion more for subsidies.

FILE - Arminda Murillo, 54, reads a leaflet on Obamacare at a health insurance enrollment event in Cudahy, Calif., March 27, 2014.


And subsidies don't help all customers. Some make too much money to qualify. And an estimated 5 million to 9 million people buy individual policies outside and state markets that offer financial assistance.

Independent analyst Caroline Pearson of the consulting firm Avalere Health said the administration should be concerned about the apparent slowdown in new consumers.

"At this time, enrollment appears to be slightly behind the pace needed to reach the administration's goal of signing up 13.8 million people," she said. "However, if more people who are currently in the market renew their coverage, then that goal could still be achieved."

Targeting new customers's advertising in the closing weeks of open enrollment will be aimed at attracting new customers, said HHS Secretary Burwell. In addition, the IRS will be sending people who paid fines for being uninsured a not-too-subtle nudge, reminding them that they can avoid higher penalties for 2017 by signing up now.

Republicans plan to repeal Obamacare early next year, but it could take up to several years to replace it. During the interlude, party leaders have promised an orderly transition to a new system. It's unclear what that would involve, but presumably some of the law's popular provisions — such as subsidies and protection for those with pre-existing medical conditions — would be kept in place.

The 2010 health overhaul added coverage for about 20 million people through a combination of subsidized private health insurance and a state option to expand Medicaid. Several Republican states adopted the Medicaid expansion, including Indiana under Pence.