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Executive Calendar

Floor Speech

By: James Lankford

Date: July 10, 2019

Location: Washington, DC

Issues: Health Insurance

BREAK IN TRANSCRIPT

Mr. LANKFORD. Mr. President, I rise to talk to this body again about healthcare and the cost of healthcare. This has been an issue and an ongoing dialogue for a long time around the Senate and around Congress.

It is an issue that was supposedly settled when the Affordable Care Act was passed, but, ironically enough, my Democratic colleagues have now joined Republicans in saying they want to repeal and replace the Affordable Care Act. They are not using the term ``repeal and replace''; they are just saying they want to do Medicare for All. Built into that is completely taking out the Affordable Care Act and replacing it with something different.

So, ironically, in some ways, we are in the same spot. We have both come to the same realization that the Affordable Care Act didn't pass-- it actually did pass, but it is not working. So now the challenge is what to do with healthcare.

We are now trying to break into pieces what we can actually do together to get this done, beginning with the cost of prescription drugs.

I continue to hear from Oklahomans all over the State about how hard it is to deal with the cost of prescription drugs, how rapidly the costs are increasing, and how sporadic the cost changes really are. They will have a drug that costs a small amount one month and come back a month later and find a dramatic increase for the exact same drug. They can go pharmacy to pharmacy and find a different price for the exact same drug or find that the pharmacy closest to them doesn't offer that drug, and a different pharmacy is the only one that is allowed to have that drug. The complexity is driving them crazy and rightfully so.

As we peel back the layers on pharmacy issues, we are finding that the complexity is that cost overruns being built in are too high.

For the past few months, we have looked at every step in the drug process, from the approval to research and development, to try to figure out how the cost is actually getting to the consumer.

Along the way, several things have occurred. The administration has aggressively been approving generics. In fact, the administration has approved a record number of generics. Those generic pharmaceuticals are much less expensive than the branded pharmaceuticals. Many of those have been waiting a very long time at the Food and Drug Administration to actually be approved. The Food and Drug Administration is rapidly getting those out the door, and that helps consumers.

Something else we have done in Congress is to try to address something called the gag clause. The gag clause is one of those things that was behind the scenes that no one knew about except for the pharmacists because, if you came in with your insurance card to pick up your prescription, the pharmacist knew the actual cost you would pay if you paid in cash. Often, you could get that same prescription for less by paying in cash than you could if you were to pay with your insurance card, but the pharmacist was prohibited from actually telling you that. We have addressed that in Congress, in a bipartisan way, to release that gag clause and allow pharmacists to actually tell people their options on pricing.

You might say: That is an absolutely crazy thing. Who put that gag rule in?

Well, the system, and the structure behind the scenes that negotiates all of it, said: If you want to be a pharmacy that sells these drugs, you have to submit to these rules. As we found, the culprit behind many of these issues is a group called pharmacy benefit managers. You will hear it referred to as just the PBMs.

Those pharmacy benefit managers are supposed to negotiate between the manufacturers and the insurance plans to lower the prices. In many areas, they have lowered prices, but they have also given preferred formulary placement to some of their preferred pharmacies so some pharmacies get that drug and other pharmacies that are competing with them don't get access to that drug. Often, it is the drug that is the highest margin drug only their pharmacies will get and other pharmacies will not.

It has become an anti-competitive piece in the background, when it was supposed to be something that was a highly competitive piece to actually help the consumer.

Unfortunately, PBMs have created one of the most elaborate, complex, and opaque system of pricing, which has a tremendous amount of market distortion and at times has limited patients' access to those drugs. Oftentimes, it is a system they have been able to take advantage of and have created financial incentives to help their bottom line in the process rather than actually help the consumer.

Many consumers have heard about rebates, but they wonder who is getting a rebate. They go to their pharmacy to pay for their drugs, and they are not getting the rebate. There is a rebate going somewhere, just not to them.

Here is the challenge. We are trying to peel back with greater transparency what is happening in the pharmacy benefit manager world and figure out how a small group--it is actually three companies that have 90 percent of the market nationwide, how that middleman in the process actually handles pricing and negotiation.

If you talk to any pharmacist anywhere in the country--and certainly across my great State--who is an independent pharmacist, they will all express their frustration with pharmacy benefit managers and their access to some drugs and not others and the stipulations they deliberately put there to hurt them and help others.

I have joined my colleague Senator Cantwell in trying to shine some light on the operations of PBMs within the drug chains. Consumers deserve greater transparency. That will help us understand the actual cost of drugs and how those costs are actually getting to consumers or not to consumers in the process. The PBMs need greater examination, and we are finally taking that up to walk through the process.

On the Finance Committee, we are dealing with several issues. Led by Senator Grassley, we are walking through Part B of Medicare, Part D of Medicare, and trying to examine what can be done to help the actual consumer. Our goals are how do we actually increase the options in drugs that are out there, how do we stop the cost increases, and how do we decrease out-of-pocket costs for pharmaceuticals.

In Part B--these are drugs that are often intravenous, but they are done in a hospital setting or in an inpatient setting. As we are working through that process, we are trying to find the perverse incentives that are built in because, right now, physicians are actually paid a percentage of the medicine they prescribe in Part B. That means if there are three medications that are out there, if a doctor prescribes the highest cost medication, they get a much higher reimbursement. It is not a flat amount. Now, all three may be intravenous, but whichever is the most expensive actually helps the doctor the most. I am not challenging doctors and saying they are always prescribing the branded drugs and the most expensive in the process--that is between the doctor and the patient to determine--but there is no doubt a perverse incentive is built into this; that if they prescribe a more expensive drug, the doctor and his office actually benefit from it. We need to fix that.

In Part D, there are reforms that can actually slow the growth in cost increases and allow people to have greater access to drugs. We are not interested in some kind of formula where we are actually going to decrease the patients' options of what drugs they can actually get in their formulary. That is a great thing about being an American; that we don't have limited formularies. It is very open in the process so Americans can try different pharmaceuticals to see which one works best for them. That is not chosen by government; it is chosen by them and their doctors. The Part D definitely needs a redesign of the benefit structure because right now things like the doughnut hole drive up costs for consumers. We are exploring a way to limit the out-of-pocket costs for beneficiaries so there is a lifetime cap sitting out there. There is an opportunity to know that if I end up with cancer or some other rare disease, I am not going to have these out-of-control costs on the pharmaceutical side and know there is not a doughnut hole waiting for me, where when I get a couple thousand dollars in, I am suddenly going to have a very expensive time. So I can afford my insurance in January, February, and March, but from April to August, I can't afford prescriptions anymore. We can't have that. We have to address those issues because that dramatically affects the out-of- pocket costs.

There are lots of other options we are looking at while working through this process, like the rebates, as I mentioned before, actually getting to the consumer, not to the companies behind the scenes, and dealing with how to take greater advantage of biosimilar drugs--very similar to the generic drugs but just in a different category and at a reduced cost--to allow them to have opportunities to get to those drugs faster. We have to deal with some of the patent issues to make sure drug manufacturers can't hold on to their patents abnormally long so the generics can't actually get out to people or bundle them together to restrict their patents.

We have to end this practice of surprise medical bills. Some folks have no idea what that is, and other folks know all too well. They look at their insurance. They go to a hospital that is in network, and their doctor is in network. So they go to a hospital that is in network, and they go to a doctor who is in network, but they get a giant bill from an out-of-network anesthesiologist, or the lab is out of network and the hospital is in network, and they get a giant bill from the lab. We are working to end the practice of having labs that are out of network or certain specialists a doctor has sent them to--the patient assumes they are in network, but then they find out that certain individuals who have taken care of them are out of network.

We are also dealing with the issue of air ambulance surprise bills, which has been a great challenge for those folks in rural America who are having to be transferred long distances to get to a hospital and then are getting an enormous bill for an out-of-network air ambulance as a surprise billing. There are ways we can address this to deal with the out-of-pocket costs.

We are focused on areas where we can find agreement and things we can do to work through this process.

There is much to be done in the area of prescription drugs and in the area of in network, out of network, and surprise medical bills. We should be able to find common ground, and I am grateful I am part of this dialogue to help try to find ways we can come together, get this resolved, and get a better situation for American consumers and patients in the days ahead.

BREAK IN TRANSCRIPT

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SIGNING_BACKEND	`'django.core.signing.TimestampSigner'`
SILENCED_SYSTEM_CHECKS	`['models.E007', 'fields.E311', 'fields.E903']`
SIMPLE_JWT	`{'ACCESS_TOKEN_LIFETIME': '******************', 'REFRESH_TOKEN_LIFETIME': '******************'}`
SITE_ID	`1`
SOCIAL_AUTH_BACKEND_ERROR_URL	`'/login'`
SOCIAL_AUTH_RAISE_EXCEPTIONS	`False`
STAFF_PHOTO_PATH	`'images/staff'`
STATICFILES_DIRS	`['/var/www/justfacts/assets']`
STATICFILES_FINDERS	`['django.contrib.staticfiles.finders.FileSystemFinder', 'django.contrib.staticfiles.finders.AppDirectoriesFinder']`
STATICFILES_STORAGE	`'django.contrib.staticfiles.storage.StaticFilesStorage'`
STATIC_ROOT	`'/var/www/justfacts/static/'`
STATIC_URL	`'/static/'`
TEMPLATES	`[{'APP_DIRS': True, 'BACKEND': 'django.template.backends.django.DjangoTemplates', 'DIRS': ['/var/www/justfacts/templates', '/var/www/justfacts/sidebyside/sidebyside_react_app/'], 'OPTIONS': {'context_processors': ['django.template.context_processors.debug', 'django.template.context_processors.request', 'django.contrib.auth.context_processors.auth', 'django.contrib.messages.context_processors.messages']}}]`
TESTING	`False`
TEST_NON_SERIALIZED_APPS	`[]`
TEST_RUNNER	`'django.test.runner.DiscoverRunner'`
THOUSAND_SEPARATOR	`','`
TIME_FORMAT	`'P'`
TIME_INPUT_FORMATS	`['%H:%M:%S', '%H:%M:%S.%f', '%H:%M']`
TIME_ZONE	`'UTC'`
TWITTER_CONSUMER_KEY	`'********************'`
TWITTER_CONSUMER_SECRET	`'********************'`
USE_I18N	`True`
USE_L10N	`True`
USE_THOUSAND_SEPARATOR	`False`
USE_TZ	`False`
USE_X_FORWARDED_HOST	`False`
USE_X_FORWARDED_PORT	`False`
WSGI_APPLICATION	`'justfacts_project.wsgi.application'`
X_FRAME_OPTIONS	`'DENY'`
YEAR_MONTH_FORMAT	`'F Y'`

Signal	Receivers
class_prepared
connection_created	register_type_handlers
got_request_exception
m2m_changed
post_delete
post_init	ImageField.update_dimension_fields, ImageField.update_dimension_fields, ImageField.update_dimension_fields
post_migrate	create_permissions, create_contenttypes, create_default_site
post_save	create_user_profile, TagField._save
pre_delete	clear_site_cache
pre_init
pre_migrate	inject_rename_contenttypes_operations
pre_save	clear_site_cache, set_zip4_userprofile
request_finished	close_old_connections, close_caches, reset_urlconf
request_started	reset_queries, close_old_connections
setting_changed	reset_cache, clear_cache_handlers, update_installed_apps, update_connections_time_zone, clear_routers_cache, reset_template_engines, clear_serializers_cache, language_changed, localize_settings_changed, file_storage_changed, complex_setting_changed, root_urlconf_changed, static_storage_changed, static_finders_changed, auth_password_validators_changed, user_model_swapped, update_toolbar_config, reset_hashers, reload_api_settings, reload_api_settings, uninstall_if_needed, clear_caches, FileSystemStorage._clear_cached_properties, FileSystemStorage._clear_cached_properties, FileSystemStorage._clear_cached_properties, FileSystemStorage._clear_cached_properties, StaticFilesStorage._clear_cached_properties

Path	Location
.DS_Store	/var/www/justfacts/assets/.DS_Store
.well-known/apple-developer-merchantid-domain-association	/var/www/justfacts/assets/.well-known/apple-developer-merchantid-domain-association
pdfs/Mobile_Messaging_Terms_and_conditions.pdf	/var/www/justfacts/assets/pdfs/Mobile_Messaging_Terms_and_conditions.pdf
pdfs/CNIP-signed-bylaws-2023.pdf	/var/www/justfacts/assets/pdfs/CNIP-signed-bylaws-2023.pdf
pdfs/PolicyforFundraisingandGiftAcceptance_1.3_Edition.pdf	/var/www/justfacts/assets/pdfs/PolicyforFundraisingandGiftAcceptance_1.3_Edition.pdf
pdfs/CNIP2018.pdf	/var/www/justfacts/assets/pdfs/CNIP2018.pdf
pdfs/CNIP2019.pdf	/var/www/justfacts/assets/pdfs/CNIP2019.pdf
pdfs/2021/162017-Vote Smart-Brochure-Proof.pdf	/var/www/justfacts/assets/pdfs/2021/162017-Vote Smart-Brochure-Proof.pdf
pdfs/2021/990-2021.pdf	/var/www/justfacts/assets/pdfs/2021/990-2021.pdf
pdfs/2020/CNIP2020.pdf	/var/www/justfacts/assets/pdfs/2020/CNIP2020.pdf
pdfs/2020/Vote-Smart-FY21-Audit-Report-Final-Signed.pdf	/var/www/justfacts/assets/pdfs/2020/Vote-Smart-FY21-Audit-Report-Final-Signed.pdf
pdfs/2020/VoteSmartbrochure.pdf	/var/www/justfacts/assets/pdfs/2020/VoteSmartbrochure.pdf
pdfs/forcandidates/2023_states/2023_New_Jersey_State_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/2023_states/2023_New_Jersey_State_PCT.pdf
pdfs/forcandidates/2023_states/2023_Mississippi_State_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/2023_states/2023_Mississippi_State_PCT.pdf
pdfs/forcandidates/2023_states/2023_Virginia_State_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/2023_states/2023_Virginia_State_PCT.pdf
pdfs/forcandidates/2023_states/2023_Kentucky_State_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/2023_states/2023_Kentucky_State_PCT.pdf
pdfs/forcandidates/2023_states/2023_Louisiana_State_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/2023_states/2023_Louisiana_State_PCT.pdf
pdfs/forcandidates/states/2022_MS_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_MS_PCT.pdf
pdfs/forcandidates/states/2022_IN_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_IN_PCT.pdf
pdfs/forcandidates/states/2022_AL_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_AL_PCT.pdf
pdfs/forcandidates/states/2022_WY_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_WY_PCT.pdf
pdfs/forcandidates/states/2022_NY_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_NY_PCT.pdf
pdfs/forcandidates/states/2022_NJ_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_NJ_PCT.pdf
pdfs/forcandidates/states/2022_SC_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_SC_PCT.pdf
pdfs/forcandidates/states/2022_MA_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_MA_PCT.pdf
pdfs/forcandidates/states/2022_NM_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_NM_PCT.pdf
pdfs/forcandidates/states/2022_NB_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_NB_PCT.pdf
pdfs/forcandidates/states/2022_MD_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_MD_PCT.pdf
pdfs/forcandidates/states/2022_MO_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_MO_PCT.pdf
pdfs/forcandidates/states/2022_MINN_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_MINN_PCT.pdf
pdfs/forcandidates/states/2022_AZ_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_AZ_PCT.pdf
pdfs/forcandidates/states/2022_PA_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_PA_PCT.pdf
pdfs/forcandidates/states/2022_OK_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_OK_PCT.pdf
pdfs/forcandidates/states/2022_OH_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_OH_PCT.pdf
pdfs/forcandidates/states/2022_NV_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_NV_PCT.pdf
pdfs/forcandidates/states/2022_WA_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_WA_PCT.pdf
pdfs/forcandidates/states/2022_FL_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_FL_PCT.pdf
pdfs/forcandidates/states/2022_MI_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_MI_PCT.pdf
pdfs/forcandidates/states/2022_CO_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_CO_PCT.pdf
pdfs/forcandidates/states/2022_OR_PCT.pdf	/var/www/justfacts/assets/pdfs/forcandidates/states/2022_OR_PCT.pdf

Path	Location
admin/img/icon-no.svg	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/icon-no.svg
admin/img/README.txt	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/README.txt
admin/img/icon-yes.svg	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/icon-yes.svg
admin/img/inline-delete.svg	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/inline-delete.svg
admin/img/selector-icons.svg	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/selector-icons.svg
admin/img/icon-calendar.svg	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/icon-calendar.svg
admin/img/search.svg	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/search.svg
admin/img/LICENSE	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/LICENSE
admin/img/icon-unknown.svg	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/icon-unknown.svg
admin/img/icon-viewlink.svg	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/icon-viewlink.svg
admin/img/icon-changelink.svg	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/icon-changelink.svg
admin/img/calendar-icons.svg	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/calendar-icons.svg
admin/img/icon-alert.svg	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/icon-alert.svg
admin/img/icon-unknown-alt.svg	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/icon-unknown-alt.svg
admin/img/tooltag-add.svg	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/tooltag-add.svg
admin/img/icon-addlink.svg	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/icon-addlink.svg
admin/img/sorting-icons.svg	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/sorting-icons.svg
admin/img/icon-clock.svg	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/icon-clock.svg
admin/img/icon-deletelink.svg	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/icon-deletelink.svg
admin/img/tooltag-arrowright.svg	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/tooltag-arrowright.svg
admin/img/gis/move_vertex_off.svg	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/gis/move_vertex_off.svg
admin/img/gis/move_vertex_on.svg	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/img/gis/move_vertex_on.svg
admin/fonts/README.txt	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/fonts/README.txt
admin/fonts/LICENSE.txt	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/fonts/LICENSE.txt
admin/fonts/Roboto-Regular-webfont.woff	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/fonts/Roboto-Regular-webfont.woff
admin/fonts/Roboto-Light-webfont.woff	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/fonts/Roboto-Light-webfont.woff
admin/fonts/Roboto-Bold-webfont.woff	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/fonts/Roboto-Bold-webfont.woff
admin/js/SelectFilter2.js	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/js/SelectFilter2.js
admin/js/nav_sidebar.js	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/js/nav_sidebar.js
admin/js/core.js	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/js/core.js
admin/js/popup_response.js	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/js/popup_response.js
admin/js/collapse.js	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/js/collapse.js
admin/js/autocomplete.js	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/js/autocomplete.js
admin/js/change_form.js	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/js/change_form.js
admin/js/jquery.init.js	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/js/jquery.init.js
admin/js/calendar.js	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/js/calendar.js
admin/js/urlify.js	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/js/urlify.js
admin/js/cancel.js	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/js/cancel.js
admin/js/prepopulate_init.js	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/js/prepopulate_init.js
admin/js/actions.js	/usr/local/lib/python3.12/dist-packages/django/contrib/admin/static/admin/js/actions.js