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A common practice of health insurance companies is requiring us to use the medicines they prefer rather than what our doctor prescribes.
Thomas R. Johnson
Published: 24 February 2023

In her best-selling book, The Hate U Give, author Angie Thomas wrote, “intentions always look better on paper than in reality.” With those words, she could well have been describing the health status of communities of color. Even with the best of intentions from elected officials and policymakers about advancing equity and eliminating health disparities, the reality is that we have a worsening health care situation in the United States, and Oregon specifically, and we’re still lacking in solutions to remedy the problem.

A core question underserved communities face on a daily basis: can we access and can we afford the medicines we need for the maladies – diabetes, heart disease, sickle cell disease – that strike patients in disproportionate and distressing numbers? For far too many, that answer is no and the ramifications of that are seen in the number of tragically shortened lives.

Last year, there was much talk that the high cost of prescription drugs had been addressed by the congressional passage of the Inflation Reduction Act. Yes, that legislation took some positive steps, primarily in reducing future costs for medicines used by Medicare beneficiaries. It didn’t, however, offer meaningful help today for those facing unaffordable out-of-pocket costs at their pharmacies and living at the mercy of insurance companies and the corporate middlemen who actually set drug prices.

The most recent Oregon health assessment produced by the state government told us what we’re facing without tangible, effective solutions to make medicines more accessible and affordable. African-Americans are having significantly more years of potential life lost than whites due to chronic, treatable conditions like heart disease and diabetes. If communities don’t have accessible, affordable prescription drugs, no matter how good the intentions of political leaders, this equity gap won’t close.

Corporate middlemen hold the power

We need solutions that target the real problem. Those aforementioned corporate middlemen, known as pharmacy benefit managers or PBMs, have the power to determine whether prescription drugs are accessible and affordable. Three large Fortune 25 companies control the marketplace and they are using their power to achieve enormous profits at our expense. This was detailed in a report last year from the Oregon State Pharmacy Association, showing how the PBMs are charging wildly excessive prices for many medicines. For a multiple sclerosis drug with a list price of $350, for example, the PBMs charged the Oregon Medicaid program nearly $3,000.

They negotiate discounts and rebates from the drug manufacturers, but don’t pass those along to the patients at the pharmacy counter.

And because they control the drug formularies, they can limit our access to lower-priced generic medicines and force us to either pay the price for higher-cost drugs or skip getting our prescriptions filled altogether.

Insurance companies don't always follow doctors' orders

And then you factor in common practices from health insurance companies, such as requiring us to use the medicines they prefer rather than what our doctor prescribes, and you better understand the daily obstacles that we face that politicians in Washington, D.C. haven’t addressed.

We need our political leaders to bring a new way of thinking to the challenge of prescription drug affordability and accessibility, one that focuses on what is taking place in the real world where too many people of color are facing serious illnesses and are being harmed by a broken health care system. Solutions that are politically popular, such an upper reimbursement limit on certain medicines, can do more harm than good by making essential drugs even less accessible.

Rather, we must focus on the insurance companies and PBMs that have the power to make medicines more affordable, but are choosing to prioritize their profits instead. They should share the discounts they negotiate with consumers, stop using formulary powers to block access to affordable drugs, and quit getting between patients and their doctors. Good intentions regarding health equity and eliminating disparities can lead to progress, but only if they are accompanied by strong-minded actions.

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