[Senate Hearing 117-363]
[From the U.S. Government Publishing Office]





                                                        S. Hrg. 117-363
 
                     LOWERING HEALTH CARE COSTS FOR
                 NEVADA SENIORS: TAKING ACTION TO BRING
                     DOWN PRESCRIPTION DRUG PRICES

=======================================================================

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS


                             SECOND SESSION

                               __________

                           LAS VEGAS, NEVADA

                               __________

                            AUGUST 23, 2022

                               __________

                           Serial No. 117-22

         Printed for the use of the Special Committee on Aging
         
         
         
         
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]         
         
         


        Available via the World Wide Web: http://www.govinfo.gov
        
        
        
        
                         ______                       


             U.S. GOVERNMENT PUBLISHING OFFICE 
 48-558 PDF           WASHINGTON : 2022 
         
        
        
                       SPECIAL COMMITTEE ON AGING

              ROBERT P. CASEY, JR., Pennsylvania, Chairman

KIRSTEN E. GILLIBRAND, New York      TIM SCOTT, South Carolina
RICHARD BLUMENTHAL, Connecticut      SUSAN M. COLLINS, Maine
ELIZABETH WARREN, Massachusetts      RICHARD BURR, North Carolina
JACKY ROSEN, Nevada                  MARCO RUBIO, Florida
MARK KELLY, Arizona                  MIKE BRAUN, Indiana
RAPHAEL WARNOCK, Georgia             RICK SCOTT, Florida
                                     MIKE LEE, Utah
                              ----------                              
                 Stacy Sanders, Majority Staff Director
                 Neri Martinez, Minority Staff Director
                 
                         C  O  N  T  E  N  T  S

                              ----------                              

                                                                   Page

Opening Statement of Senator Jacky Rosen, Member of the Committee     1

                           PANEL OF WITNESSES

Maria Moore, State Director, AARP, Las Vegas, Nevada.............     3
Christina Madison, Pharm.D., FCCP, AAHIVP, Founder and CEO, The 
  Public Health Pharmacist, PLLC., Las Vegas, Nevada.............     5
Jeffrey Klein, FACHE, President and CEO, Nevada Senior Services 
  Inc., Las Vegas, Nevada........................................     7
Regina Milner, Patient Advocate, Las Vegas, Nevada...............     9

                                APPENDIX
                      Prepared Witness Statements

Maria Moore, State Director, AARP, Las Vegas, Nevada.............    31
Christina Madison, Pharm.D., FCCP, AAHIVP, Founder and CEO, The 
  Public Health Pharmacist, PLLC., Las Vegas, Nevada.............    34
Jeffrey Klein, FACHE, President and CEO, Nevada Senior Services 
  Inc., Las Vegas, Nevada........................................    37
Regina Milner, Patient Advocate, Las Vegas, Nevada...............    42


                     LOWERING HEALTH CARE COSTS FOR

                 NEVADA SENIORS: TAKING ACTION TO BRING

                     DOWN PRESCRIPTION DRUG PRICES

                              ----------                              


                        TUESDAY, AUGUST 23, 2022

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2 p.m., at 
College of Southern Nevada Board of Regents, 3200 E. Cheyenne, 
North Las Vegas, Nevada, Hon. Jacky Rosen, Member of the 
Committee, presiding.
    Present: Senator Rosen

                 OPENING STATEMENT OF SENATOR 
              JACKY ROSEN, MEMBER OF THE COMMITTEE

    Senator Rosen. Good morning, the Senate Aging Committee 
will come to order. I am glad to be here today, and I want to 
thank the College of Southern Nevada for hosting this important 
hearing. I also want to thank our witnesses and everyone who 
has been able to join us here in person, as well as those, of 
course, watching online.
    We are holding this morning's field hearing in Las Vegas to 
discuss a pressing need for Nevada's seniors, lowering the high 
cost of prescription drugs. The past two and a half years have 
been incredibly challenging for so many Nevadans, and as we 
work to finally put the COVID-19 pandemic in the rearview 
mirror, we must continue to invest in the health and well-being 
of our most vulnerable, especially our seniors.
    What does that mean? Well, it means that making sure that 
seniors in Nevada and across the country, well that they have 
easy access to quality, affordable health care no matter what 
community they live in. It means taking steps to address the 
high cost of prescription medications, including by allowing 
Medicare to use its buying power to negotiate for lower drug 
prices, and it means capping out-of-pocket prescription drug 
spending for seniors on Medicare Part D.
    Medicare is a sacred promise. It is a promise of guaranteed 
access to health care after a lifetime of hard work. Despite 
this promise, we know that many seniors still have trouble 
affording and assessing much needed prescription medication. No 
one, and especially seniors living on fixed incomes, should 
have to choose between buying groceries and taking lifesaving 
medication, but for years, far too many Nevada seniors have 
faced this impossible choice. In fact, unfortunately, many 
seniors ration their medications or skip taking them altogether 
because of high costs, and we are going to hear real life 
stories of this today, but simply put, this is unacceptable.
    That is why after nearly 30 years of inaction, I am proud 
to have worked with my colleagues in Congress to deliver on the 
promises that so many have previously made and to finally, 
finally lower drug costs.
    We are bringing about real relief for Nevada seniors and 
seniors across America, and this hearing could not be more 
timely. My Democratic colleagues and I just passed the 
Inflation Reduction Act, and just last week, President Biden 
signed this historic bill into law. This transformative new law 
will finally allow Medicare to negotiate the best price of 
prescription medication for America's seniors.
    The Inflation Reduction Act will also cap seniors' yearly 
out-of-pocket spending on prescription drugs at $2,000, and it 
will cap the price of insulin for Medicare beneficiaries at 
just $35 a month. This new law will usher in an era of 
increased access to an affordability of lifesaving prescription 
medication for Nevada's seniors, and because private insurance 
often follows Medicare, the new negotiation authority included 
in this bill could end up lowering prescription drug costs not 
only for seniors, but for all families.
    As we prepare for this new law to go into effect, I am 
thrilled to have the opportunity to hear from our excellent 
panel of witnesses today about how the high cost of drugs has 
imposed--have imposed burdens on Nevada seniors, how high drug 
costs impact seniors' health and well-being, how this impacts 
health care professionals and caregivers, and how the new law I 
helped pass will soon help reduce costs right at the pharmacy 
counter.
    I am also looking forward to hearing about how Congress can 
best implement this new law and continue our work to lower 
health care costs across the board for Nevada's seniors, 
including through legislation I have introduced. Before we 
begin, I want to remind the witnesses to please keep their 
remarks to five minutes, and with that, I am going to introduce 
all of our witnesses at once, and then we will proceed to your 
opening statements. Our first witness, Ms. Maria Moore, who 
serves as a State Director of AARP Nevada. Thank you, Maria. 
She is a longtime advocate for the aging community. Ms. Moore 
previously served as AARP Nevada's Community Outreach Director 
since 2003.
    She has also served on several boards and commissions, 
including the Nevada Commission on Aging, VA Southern Nevada 
Health Care System, Volunteer Association, and the United Way 
of Southern Nevada Emergency Food and Shelter Board. Thank you, 
Ms. Moore, for being here with us today and sharing your 
expertise with the Committee.
    Next, I will introduce Dr. Christina Madison, a Clinical 
Pharmacist and Associate Professor at Roseman University 
College of Pharmacy. Dr. Madison also works with patients at--
excuse me--at Huntridge Family Clinic, one of the largest 
providers of HIV prevention and gender affirming care in 
Nevada, and volunteers in medicine of Southern Nevada, where 
she provides immunization and communicable disease care.
    As a Clinical Pharmacist, Dr. Madison has seen firsthand 
the roadblocks that patients experience in trying to access 
their prescription medications. As an Associate Professor, she 
has supported residents and fellows as they begin their own 
journeys into pharmacy care. Thank you, Dr. Madison, for being 
with us today and sharing your expertise with the Committee.
    Our next witness, Mr. Jeff Klein. He is President and CEO 
of Nevada Senior Services. Nevada Senior Services is a health 
care organization that works to find ways to make health care 
more affordable and accessible for seniors all across the Las 
Vegas Valley. Prior to his service at Nevada Senior Services, 
Mr. Klein founded Altila Associates, where he conducted and 
supervised extensive engagements for hospitals, medical groups, 
and academic centers.
    He has also spent time in health care leadership and 
hospital management in New York State. Thank you for being here 
and sharing your expertise with us, and finally, our next 
witness is Ms. Regina Milner from Las Vegas. Ms. Milner, well 
she is a patient advocate and Medicare beneficiary who 
personally knows the struggle of managing multiple health 
conditions and affording her many medications.
    She will share the stress and the burden that she has faced 
during her own health journey to access lifesaving insulin and 
the other medications that she needs. Thank you, Ms. Milner, 
for being with us today and for sharing your personal 
experience with the Committee, and of course, all of us across 
the country.
    I am going to proceed now to witness testimony. We will 
begin with Ms. Moore. You may begin your testimony. Thank you.

                   STATEMENT OF MARIA MOORE, 
            STATE DIRECTOR, AARP, LAS VEGAS, NEVADA

    Ms. Moore. Thank you, Senator Jacky Rosen, for having us 
here today. AARP, on behalf of our 38 million members, 
including over 300,000 members in Nevada and all older 
Americans nationwide, appreciates the opportunity to submit 
testimony on this important hearing of the Senate Aging 
Committee.
    AARP has been fighting for decades to make prescription 
drugs more affordable, which is why we pushed so hard for drug 
pricing provisions in the recently enacted Inflation Reduction 
Act of 2022. These new policies will go a long way to lower 
drug prices and out-of-pocket costs for older Nevadans.
    We thank Senator Rosen for her support of this law and the 
Senate Aging Committee for this--for its recent hearings and 
other efforts to keep prescription drug pricing reform in the 
spotlight. For perspective on this historic nature of this new 
law, it is important to fully understand the difficulty that so 
many older Americans face in trying to afford the medications 
they need to stay healthy.
    On average, Medicare Part D enrollees take between four and 
five prescriptions per month, often for chronic conditions that 
will require treatment for the rest of their lives. At the same 
time, Medicare beneficiaries have a median annual income of 
just under $30,000. One quarter have less than $8,500 in 
savings.
    In Nevada, the average annual cost of prescription drug 
treatment increased 26.3 percent between 2015 and 2019, while 
the annual income for Nevada residents only increased 18.8 
percent. This population simply does not have the resources to 
absorb the rapidly escalating prescription drug prices, and 
many are really facing the reality of having to choose between 
their medications and rising prices of other basic needs, such 
as housing or food.
    We know the number one reason someone does not fill a 
prescription is because of its costs. For years, prescription 
drug prices increases have dwarfed even the highest rates of 
general inflation. If consumer prices had risen as fast as drug 
prices over the last 15 years, gas would now cost $12.20 a 
gallon, and milk would be $13 a gallon.
    Just in January, the drug industry raised prices on over 
800 prescription medications, just as they have increased 
prices for decades, including three quarters of the top 100 
drugs with the highest spending in Medicare Part D. After years 
of promises, Congress has enacted the historic changes in the 
Inflation Reduction Act.
    This new law will finally require Medicare to leverage its 
buying power and begin to negotiate with drug companies for 
lower prices. The provisions will apply to a growing number of 
drugs that are among the highest cost to consumers in Medicare, 
resulting in substantial savings for both seniors and 
taxpayers.
    The Congressional Budget Office estimates this policy alone 
will save Medicare nearly $100 billion over 10 years. The law 
will also give peace of mind to millions of seniors with high 
drug costs by capping their out-of-pocket Part D drug spending 
at $2,000 per year. There is currently no cap on these costs, 
and many Medicare beneficiaries simply do not have the 
financial resources to fill prescriptions that cost them 
$10,000 or more every year.
    The law also caps insulin co-pays in Part D at $35 a month, 
which will help--which will be a major help for the roughly one 
in three Medicare beneficiaries with diabetes. These are 
incredibly important policies that will not only save millions 
of Americans, but it will also save lives.
    The Inflation Reduction Act will also require drug 
companies to pay penalties if they raise their prices faster 
than inflation. This policy will address the long standing 
practice of drug companies raising their prices year after 
year, often at more than twice the rate of inflation. This will 
help rein in seniors out of pocket cost sharing and Medicare 
drug premiums. In addition, the Inflation Reduction Act will 
make available certain recommended vaccines for seniors on 
Medicare with no cost sharing, like the shingles vaccine that 
has a list price around $350.
    This policy already applies to Medicare Part B covered 
vaccines and a small group of private markets, but for years, 
Medicare beneficiaries have had to pay some level of cost 
sharing for Medicare Part D covered vaccines, depending on 
their plan coverage. This will not only save seniors out-of-
pocket costs but is also an important preventative benefit to 
help older adults from illness.
    Approximately 4.1 million Medicare beneficiaries received a 
vaccine covered under Part D in 2020. This new law is a 
historic victory for families across the country who are 
struggling to afford their prescriptions, but the fight isn't 
over. Big drug companies will spend millions trying to overturn 
or undermine the law so they can keep charging Americans the 
highest prices in the world.
    AARP will keep fighting big drug companies' out of 
controlled prices and we won't back down. Thank you again to 
the Special Aging Committee for holding this hearing in Nevada, 
and to Senator Rosen for inviting us here to raise awareness 
about this critical issue. Thank you.
    Senator Rosen. Thank you, Ms. Moore.
    We will now turn to Dr. Madison. You may begin your 
testimony.

        STATEMENT OF CHRISTINA MADISON, PHARM.D., FCCP,

           AAHIVP, FOUNDER AND CEO, THE PUBLIC HEALTH

              PHARMACIST, PLLC., LAS VEGAS, NEVADA

    Dr. Madison. I first want to take a moment to thank Senator 
Rosen for hosting this Committee meeting, focusing on an 
extremely important topic of prescription drug cost and how it 
impacts our Nevada seniors. Let me first take a moment to 
introduce myself. My name is Dr. Christina Madison. I am a 
Clinical Pharmacist and Associate Professor of pharmacy 
practice.
    I am also the Founder and CEO of the Public Health 
Pharmacist, which is a consulting firm specifically focused on 
public health. I have been training the next generation of 
allied health professionals, including pharmacy students and 
pharmacy residents, as well as medical physician assistant and 
nurse practitioner students for the past 15 years.
    In my nearly two-decade career, I have spent counseling 
patients on how to treat and prevent the spread of infectious 
diseases, and for the past two years, I have been working 
overtime on the COVID-19 response, providing vaccinations, 
testing, and treatment.
    I have personally facilitated the administration of over 
12,000 doses of the COVID-19 vaccine, and now I am helping to 
coordinate the monkeypox response through the increased access 
to vaccinations, which are currently in limited supply. My work 
over the years, and especially during the pandemic, has put a 
spotlight on the need to focus on health equity, which includes 
access to affordable prescription drugs.
    It is my honor and privilege to provide witness testimony 
as a public health advocate who has dedicated my professional 
career to caring for the underserved and vulnerable 
populations. I am thrilled to be sitting here with you today 
following the recent passage and sign it into law of the 
Inflation Reduction Act by President Biden on August 16th.
    This new law is an historic down payment on a deficit 
reduction to fight inflation, invest in domestic energy 
production and manufacturing, and will reduce carbon emissions 
by roughly 40 percent by 2030. More pertinent to this hearing 
is the fact that this law will also allow Medicare to negotiate 
for prescription drug prices and extend the expanded Affordable 
Care Act program for three years through 2025.
    Our country is on the verge of another health crisis, and 
seniors across Nevada are struggling with affordable care and 
coverage. Addressing health disparities and inequities is one 
of the main focuses of public health, and as a patient 
advocate, I know firsthand the importance of making sure 
patients have their basic needs met, which includes making sure 
that they have access to their medications by making them more 
affordable.
    Understanding that seniors, in particular those in the 
BIPOC community, or APPI, and Indigenous brothers and sisters 
are facing more than just issues with their medications, but 
just getting to their doctor's visits in the first place, as 
well as structural racism and historic trauma. With most 
seniors taking multiple medications and having issues with 
polypharmacy, we know that several are having to make the 
difficult decision of paying rent, groceries, or gas, before 
paying for their prescription medications.
    More and more are accessing food pantries and donations to 
supplement getting their basic needs met in order to afford 
their medications while living on fixed incomes. The passage of 
the Inflation Reduction Act of 2022 is going to make a 
meaningful and measurable difference in the lives of Nevadans.
    Nevada residents are being disproportionately impacted by 
high prescription drug prices. Per AARP, over 200,000 Nevadans 
have been diagnosed with diabetes. Almost 270 Nevadans have 
been diagnosed with either asthma or COPD, and over 230,000 
Nevadans have been diagnosed with some form of cancer. These 
are three very expensive disease States that require chronic, 
high cost prescription medications.
    For example, between the years 2015 and 2020, the price 
difference of these medications are as follows. Victoza, which 
is a very common treatment for diabetes, went from a little 
under $8,000 to over $11,000 per year. Another medication, 
Revlimid, used to treat some forms of cancer, went from 
$185,000 to over $260,000.
    Last but not least, Spiriva Handihaler, used to treat COPD, 
went from almost $4,000 per year to over $5,000 per year, just 
in a span of five years. We know that this represents a 
significant price increase that far exceeds normal increase due 
to inflation. These are just a couple of examples of the 
exorbitant drug costs that seniors are currently experiencing.
    As I work with nonprofits and community partners, I see 
that more and more people are accessing these types of social 
services in order to just deal with their every day. Everything 
costs more, but that shouldn't include necessary lifesaving 
medications. I have conducted many medication review sessions 
called brown bag events with seniors in the community, and I 
often see them holding on to medications because they don't 
know when they may need it again.
    This is that depression era thought process. This is 
incredibly dangerous, especially if they get these older meds 
mixed up with the new medications. The first thing I do is I 
ask them what their medical conditions are, why they are taking 
each of their medications, and if they are taking them as 
directed.
    Oftentimes, there are at least a few that no longer have an 
indication or duplicated medication and can be safely 
discarded. Ultimately, I know that this generation doesn't like 
to let things go because they are used to doing more with less 
because their meds are so expensive. This just is one of these 
things that they just don't want to let go of. Did you know 
that 20 percent of all medications are never picked up at a 
pharmacy?
    Typically because of lack of transportation, perceived 
need, and ultimately cost. Reducing the cost of prescription 
medications through the Inflation Reduction Act of 2022 is 
going to help not just the cost of prescription drugs, but 
people's quality of life because they will be able to afford 
other things.
    Medications don't work if you don't have them, and you 
can't take them if you can't afford them. That is why I am 
relieved that Congress just passed the Inflation Reduction Act, 
which will help lower costs for Nevada's seniors, including for 
many of the patients I serve every day.
    This new law will be the first time that Medicare will be 
allowed to negotiate for lower drug prices in history. It will 
cap seniors' out of pocket spending at $2,000 per year and the 
price of insulin and other lifesaving medications for thousands 
of Nevada seniors at just $35 per month.
    Thank you, Senator Rosen and the congressional Democrats, 
for working to pass this legislation, which is critical, and it 
is a lifeline to so many who live here in Las Vegas. I am 
providing this testimony to bring attention to these issues and 
to discuss solutions for our struggling Nevadans so that they 
can live healthier and happier lives.
    Thank you so much for the opportunity to speak with you 
today.
    Senator Rosen. Thank you. Thank you, Dr. Madison, for your 
statement. We are going to proceed to Mr. Klein.
    Mr. Klein, you may now begin your testimony, please.

               STATEMENT OF JEFFREY KLEIN, FACHE,

                PRESIDENT AND CEO, NEVADA SENIOR

                SERVICES INC., LAS VEGAS, NEVADA

    Mr. Klein. Thank you. On behalf of Nevada Seniors Services 
and our aging community in Nevada, thank you for the 
opportunity to provide testimony to the Senate Aging Committee. 
I would be remiss if I did not thank Senator Rosen for this 
invitation to appear and for the Senator's steadfast support of 
Nevada's seniors and all our older Nevadans.
    I am also grateful to Senator Rosen, the Senate Special 
Committee on Aging, as well as other members of our 
congressional delegation, including Senator Cortez Masto, 
Representative Susie Lee, Steven Horsford, and Dina Titus for 
their support in passage of the Inflation Reduction Act of 
2022.
    I have the privilege to serve as the President and CEO of 
Nevada Senior Services, and also as a board member of both the 
American Society on Aging and the National Association of 
Nutrition and Aging Services Programs.
    A trusted nonprofit leader in aging services for Southern 
Nevada, Nevada Seniors Services provides a comprehensive range 
of quality programs and are designed to assist seniors and 
their family caregivers to live their best lives while aging in 
place. Our goal is providing remarkable care, balanced with 
culture that supports autonomy, choice, and safety.
    We accomplish this providing a no wrong door model of 
inclusive service delivery as the Aging and Disability Resource 
Center for most of Southern Nevada. We offer adult day health 
care, memory loss programs, case management, in-home respite 
and personal care, home repair and modifications, caregiver 
support programs, and Hospital2Home, which is a unique dementia 
friendly care transitions program.
    This remarkable program has achieved a less than one 
percent hospital readmission rate. Nevada Seniors Services 
serves over 2,500 seniors and their families every year. By way 
of example, Hospital2Home assists persons with complex health 
conditions, cognitive impairment, and those without home social 
supports to transition safely from the hospital to home without 
a readmission.
    Frequently, this requires immediate resourcing to ensure 
availability of critical medications, nutrition, follow on 
medical care, and psychosocial supports for family caregivers. 
Nevada Senior Services has a long history of offering vaccine 
clinics for flu, pneumonia, shingle, and most recently, COVID, 
reaching out to our most vulnerable seniors, family caregivers, 
and frontline staff.
    Our Nevada Care Connection Resource Center assists persons 
to connect to resources and to ongoing long-term services and 
supports such as medication, nutrition, housing, 
transportation, case management, and access to benefits, 
including Medicaid and SNAP. Last year, we provided over 3,500 
critical resource connections to our citizens.
    HomeMeds is our latest initiative, an evidence-based 
medication review for identifying potential medication related 
problems in collaboration with pharmacists and physicians. It 
is designed to reduce the risk of medication errors and adverse 
effects, including unnecessary medication related 
hospitalizations.
    This program targets seniors and persons with cognitive 
impairment, and it is made possible by, actually by a grant 
from the U.S. Department Administration for Community Living. 
Nevada's demographics and population characteristics make 
senior care in general and prescription medications critical 
issues to address.
    We continue to be one of the three States with the highest 
rate of growth in the over 65 population in the country and 
14.3 percent of our seniors live alone. Nearly nine in ten 
persons aged 65 or older currently taking prescription 
medicines are reporting that they take four or more 
prescription medicines.
    In addition, one-fourth of them report that it is difficult 
to report--afford their prescriptions, particularly those who 
are either in the fair or poor health status categories and 
whose income is below $30,000 annually, and who take four or 
more prescriptions. One-fifth of our older adults report not 
taking their prescriptions as prescribed due to cost.
    Many seniors are poor reporters, not sharing the decisions 
about not taking their medications as prescribed with their 
prescriber. It is not an infrequent occurrence for seniors to 
admit making difficult choices between nutrition, housing, pet 
care, and taking their prescription medications. Polypharmacy 
is a significant risk factor for hospitalizations and falls 
frequently resulting in hospitalizations.
    Medication related issues associated with seniors and 
diabetes closely correlates with falls and with medication 
related drug overdoses. The Inflation Reduction Act of 2022 
makes an important down payment in addressing these 
prescription drug issues that impact the ability of older 
Americans to have their best possible lives, aging in place 
with their family and friends. It accomplishes this by 
impacting a number of issues that have been longstanding 
priorities for our seniors, Nevada Seniors Services, ASA, 
NANASP, and many local organizations serving our aging 
community.
    Three of the priorities included in the legislation are the 
$2,000 cap on out-of-pocket costs for prescription drugs for 
those on Medicare beginning in 2025. It is estimated that over 
1.8 million older adults spend more than that amount every 
year. No co-pays or cost sharing for vaccines covered solely 
under Medicare Part D beginning in 2023.
    Expanding the low-income subsidy, the LIS, to include 
beneficiaries with incomes up to 150 percent of the poverty 
line beginning in 2024. As members of this Committee know, 
within Part D prescription drug program, START, standard 
benefits is an initial $480 deductible before coverage even 
begins. For this is a high enough barrier to forgo purchase and 
needed treatment for many of our seniors.
    The legislation allows for the first time in history for 
Medicare to negotiate for the price of drugs, unfortunately, 
not till the beginning of 2026 and starting with just ten 
drugs. It also caps co-pays for insulin for Medicare 
beneficiaries at $35 a month. As of 2024, those drugs with high 
costs enough to qualify for the program's catastrophic 
coverage, would no longer have to pick up the five percent co-
pay for each prescription.
    We have a duty to address these important issues associated 
with affordability and access to prescription medications. We 
must be committed to helping seniors manage their health span 
while their life span increases, and while they stay engaged in 
life and maintaining their independence.
    We are grateful for the support and work and contributions 
of the Senate Aging Committee in making these objectives more 
attainable. I thank the special Committee for allowing me to 
speak today, and I am very happy to take any questions.
    Senator Rosen. Thank you so much, Mr. Klein, for your 
statement. We will wrap up our witness remarks with Ms. Milner. 
Ms. Milner, please, you may begin.

                  STATEMENT OF REGINA MILNER, 
              PATIENT ADVOCATE, LAS VEGAS, NEVADA

    Ms. Milner. Thank you and your staff so much for having me 
here today to share my experience with insulin and other 
expensive prescription drugs. My name is Regina Milner. I am a 
60-year-old type I diabetic patient, a patient advocate, a 
systemic lupus warrior, and a resident of Las Vegas, Nevada.
    I am also a stiff person syndrome, rare disease warrior who 
is GAD-65 seropositive, which has also caused my type I 
diabetes. That is a genetic disorder. That is one--it is one in 
a million chance and strikes one in a million people. However, 
most importantly, I am proudest of my titles of mother and 
grandmother.
    My children and grandchildren have witnessed my 20 plus 
years of struggling and consistently advocating for diagnoses, 
medications, and equitable medical care and treatment, all 
while navigating my way through an unfair and unequal, systemic 
medical discrimination system.
    In process of--in the process of paying for my medical care 
and medication to try to maintain health as possible--my health 
as possible, I became completely indigent and I now presently 
rely on my daughter, who also suffers from autoimmune disease, 
to provide me with a roof over my head and the care that I 
need.
    My many illnesses require me to use over 20 drugs, actually 
27 drugs and medical supplies that include two specific brands 
of insulin, Tresiba and Humalog, which require prior 
authorization, as well as my Dexcom G6 device and glucose 
monitor. In addition, I take weekly injections of Benlysta for 
my lupus and autoimmune diseases. I am now in need of IVIG 
treatment.
    The cost of maintaining my health isn't cheap. One of my 
lupus medications, Benlysta, has a retail price of almost 
$5,000. It is thanks to my enrollment in Medicare Part D extra 
help program, which subsidizes my Benlysta payment to under $10 
that I can afford it. I also take insulin products and need 
insulin twice a day, but the products I use are not included in 
the formulary.
    During COVID, my glucose levels increased to over 700 while 
doctors' offices were closed, which is extremely dangerous and 
can result in diabetic coma. Unfortunately, my physicians 
didn't understand my genetic type of diabetes and told me that 
I did not need diabetes medications or insulin.
    The test results were repeatedly dismissed until I found 
myself sleeping into a coma. It took several weeks of more 
advocating for prior authorization to get the correct insulins 
that worked for my illnesses. I know all too well the dangers 
of not having access to the lifesaving medications I need.
    My father, also deceased, suffered from the same illnesses. 
Senator Rosen, your advocacy and that of your Democratic 
colleagues is so much appreciated. The Inflation Reduction Act, 
which has just been signed into law last week, will cap out-of-
pocket costs at $2,000 per year and cap insulin at $35 per 
month for people on Medicare, which is a life changing amount 
for folks like me.
    Instead of rationing or skipping medications, seniors and 
others like me across the country can finally put their health 
first without being worried about the cost. Related disease 
management and these exponential growth costs have cost me my 
quality of life. I have worked in many administrative roles.
    I used to type 90 words per minute. I now have a muscle 
disorder. I was also a game dealer for the Monte Carlo Resort 
and the casino on the Las Vegas Strip. I am a single parent, 
and I knew I had to make ends meet for my children, but the 
diseases I have made it impossible to keep a job. Capping the 
cost of prescription drugs--excuse me, my muscle disorder is 
affecting my speech--will make a difference for so many Nevada 
seniors and so many other minorities and people who are 
struggling.
    I don't have a choice in the medications I take or the 
genetic diseases I was born with, but I do see a brighter 
future, especially with the passage of the Inflation Reduction 
Act and the cost savings to come. I am losing my ability to 
verbalize myself clearly due to my muscle disorder and 
autoimmune disease.
    My next statement is loud and clear. America's seniors have 
long needed prescription drug reform and these out-of-pocket 
costs caps for many people on Medicare are the right step 
forward. I know that I am not alone in this struggle.
    There are so many of us who need our prescription drugs, 
especially in the autoimmune disease and chronically ill 
community. We can't afford to wait, but with the Inflation 
Reduction Act, thank God we won't have to. In closing, I am 
thankful to wake each day and begin each day with gratefulness, 
because it is by the grace of God that I am alive and standing 
before you today.
    In the process, I have had to fight for my life, and I have 
dealt with a lot of disparity that has resulted in me being 
misdiagnosed, receiving treatment that has endangered my 
health, and I have been barred from treatment that I should 
have received, unfortunately. I am so grateful that you have 
taken the time to listen to my story and have me here today.
    I thank you for all of your time and for listening to my 
medical experience. I know that other people are experiencing 
this as well, and I hope that I can be a help to them as well. 
Again, I sincerely and truly thank you, Senator Rosen, and all 
of your staff. They have been beautiful. They have been 
wonderful. This opportunity to share my story today, and for 
your hard work and the successes that you have accomplished to 
help us.
    Senator Rosen. Well, Ms. Milner, you are the reason why we 
all do what we do. You are the reason why we are here today. 
Your strength and your bravery is--people watching, people who 
know you. You fight for those who don't quite have the strength 
and we are so grateful that you are here. It is why we are 
here. It is why we are having the hearing, and I really, really 
appreciate you.
    I think we will get started on some questions, so if you 
need a drink, if you need anything from our team, you just let 
us know, Ms. Milner, okay? Okay, perfect. Why are we here? The 
high cost of prescription drugs, the new out-of-pocket spending 
cap. It is no secret that Americans pay far more for 
prescription drugs and people in other industrialized nations, 
and in fact, according to Rand Corporation, a recent report 
from the Rand Corporation, Americans pay more than two and a 
half times more, two and a half times more for the average 
prescription drugs than do citizens in 32 other developed 
countries, and that is when it comes to brand name drugs.
    Americans pay nearly--excuse me, when it comes to brand 
name drugs, Americans pay nearly three and a half times more 
than our counterparts in other countries. Fortunately, 
President Biden just signed into law the Inflation Reduction 
Act, which congressional Democrats recently passed.
    All of our strong support, my strong support and this new 
law, as we spoke about, you have heard, will soon cap the out-
of-pocket costs for seniors on Medicare Part D at $2,000 per 
year total no matter how many prescriptions they may take and 
no matter what those prescriptions are.
    You said there are people on sometimes 20 different 
medications. It is--there is a lot for people to navigate. Ms. 
Milner, you said how many prescription drugs do you take a 
month?
    Ms. Milner. With my prescription drugs and supplies that I 
need, including my Dexcom G6, which I am so grateful for, it 
saves my life every day, I take 27.
    Senator Rosen. 27.
    Ms. Milner. 27 prescriptions.
    Senator Rosen. You are enrolled in the Medicare Part D 
extra help program, which helps you subsidize those costs?
    Ms. Milner. Yes, ma'am, and I am so grateful. I just began 
using it this month, and this SHIP program has been so helpful 
to me in helping me to get enrolled and to understand Medicare. 
It has been a new education.
    Senator Rosen. If you didn't have this program, how much 
would you spend if you just had to pay for it?
    Ms. Milner. You know, they are still at this point 
itemizing the total cost of my drugs with my new----
    Senator Rosen. Right----
    Ms. Milner [continuing]. Part D, but at this point, it 
looks like I would be well over $15,000----
    Senator Rosen. A year----
    Ms. Milner. Benlysta is----
    Senator Rosen. Per month?
    Ms. Milner [continuing]. $5,000 by itself, per month.
    Senator Rosen. If you are estimating about $15,000 a month, 
and we are going to put in a $2,000 a year cap, that is just 
about $167 a month. I don't know, maybe you could sum that up 
in a sentence or two with how that is going to change your 
life?
    Ms. Milner. I thank God. I am so grateful because every 
morning that I wake up is a blessing and I can take my 
medication. I can still think clearly and still navigate and 
still advocate for myself. Being able to have my medication is 
a blessing. Being able to have your help, all of your help is a 
blessing. I am so thankful and grateful. That is all I can say 
is thank you.
    Senator Rosen. Well, it is coming, the help is coming, and 
so we are going to talk now a little bit about Medicare price 
negotiation, because that is really going to make a huge 
difference, because one of the core components of the Inflation 
Reduction Act, again I am so proud to help pass that, we have 
finally made it possible for Medicare to negotiate directly, 
directly with big pharmaceutical manufacturers to ensure the 
lowest possible drug prices for our seniors, and so over the 
next few years, the Department of Health and Human Services 
will be allowed to negotiate the prices of the most expensive 
drugs on the market to help lower costs for seniors in Nevada 
and across the country. Many of the most expensive drugs, which 
often have limited or no competition, are for serious 
conditions like cancer, and I am going to repeat the statistics 
for Nevada.
    Cancer impacts more than 230,000 Nevadans. My mother died 
of lung cancer. I was one of those Nevadans that--it impacted 
my family. Diabetes that impacts more than 202,000 Nevadans, 
and asthma, which affects more than 260,000 Nevadans, and so I 
am pleased that as a result of this new law--again, I can't 
reiterate enough Medicare is finally, finally going to be able 
to use its purchasing power to deliver those lower costs for 
seniors who rely, like Ms. Milner, on the lifesaving 
medication. Ms. Moore, we are going to talk about AARP Nevada.
    You have just been a longtime advocate for Medicare drug 
price negotiation, and can you just maybe give a few more words 
about not just how hard you work, but how you have come to this 
point? The Inflation Reduction Act, you were a champion.
    AARP is a champion for it. How it is going to help millions 
of Nevadans--well, millions of seniors across the country, 
Nevada seniors, of course, keep our prescription drug prices 
down.
    Ms. Moore. Thank you, Senator Rosen. As you stated, AARP 
has made the argument for many years, for decades, that with 
more than 50 million Americans getting their medications 
through Medicare, if the program was allowed to negotiate 
prices, the power of those numbers would deal a much better 
deal for Medicare beneficiaries and for taxpayers who 
ultimately foot the bill for the lion's share of the medication 
costs, and after decades of pushing for this reform, the 
Inflation Reduction Act finally authorizes Health and Human 
Services Secretary to begin negotiating the prices of ten of 
the highest costs medications or prescription drugs in 2023, 
and the negotiated prices will go into effect in 2026 for Part 
D medications, and in 2028 for drugs covered under Medicare 
Part B.
    The number of drugs whose prices will be negotiated on 
behalf of Medicare will increase in subsequent years, and by 
2029, a total of 60 drugs will be subject to a negotiated 
price--negotiated prices.
    Overall, this process will create substantial savings for 
seniors and taxpayers by reducing the prices of the growing 
number of expensive and widely used prescription drugs. The 
Congressional Budget Office estimates that this program will 
save Medicare approximately $100 billion in 10 years, and 
according to the Kaiser Family Foundation report, Medicare 
negotiation could actually drive down prices for drugs used by 
8.5 million people on Medicare, accounting for nearly one in 
five, 18 percent of the 47.7 million Medicare Part D enrollees 
in 2019.
    Senator Rosen. Thank you. You know, I think we all know 
that an ounce of prevention is worth a pound of cure, so by 
providing these medications, we can keep people healthier, 
happier. It is better for their families, of course, for their 
pocketbooks. They don't have to make choices, and most 
importantly, we can keep them away from the most expensive 
care, which is obviously going to the hospital, and so, Mr. 
Klein, I am going to turn to you, because I would say not many, 
but I would say probably all of the seniors that you serve are 
on Medicare, right, and so this Medicare negotiation provisions 
ensure that people get their medication, and they stay 
healthier. They don't have to make the choices, maybe they are 
not entering the emergency room. How do you think it is going 
to impact the work that you do and others like you?
    Mr. Klein. We are very excited about the prospect. This has 
been a long time coming. As Senator knows, the VA has been at 
this for forever, so has the Department of Defense. Every 
managed care organization negotiates prices for drugs. The 
people who have really been on the raw end of this problem are 
those people frequently who just above the poverty line, 
seniors on fixed incomes, and without a controlled drug costs, 
making those big decisions between food, pets, and life. Every 
day we go through the process of trying to find resourcing for 
people to get medication because they either have a plan that 
they can't afford, they can't afford another plan, the 
alternatives leave the costs too high, and so they are 
constantly making major health choices.
    This is the cavalry coming for those people on fixed 
incomes, and while it may not affect everybody tomorrow, it 
will over time, and with an aging population, folks who are 
going to live into their 80's, maybe 90's, the long haul here 
is really important, so we are--we think this is going to have 
a big impact day to day.
    In the short run, we think, it is going to create some 
incentives and opportunities for us to look at alternative 
medication funding mechanisms to try to help people on fixed 
incomes kind of span the time while they wait for this to 
really hit home.
    Senator Rosen. That is fantastic. We know that people 
living with chronic disease, we live better and longer, and 
that medication is what is helping that, and I am sure you work 
with many grandparents, so those grandkids are the true 
beneficiaries, perhaps, of getting to know their grandparents, 
but we are going to turn next to you, Dr. Madison, because 
nobody knows better than you than the high prescription drug, 
the costs, the impacts on patient health outcomes, compliance, 
and their health care providers, you being one of them. 
Unfortunately, we have far too often seen that the high cost of 
prescription drugs, well, it impacts both the seniors who need 
them and also the health care providers who manage their care, 
doctors, pharmacists, other health care professionals.
    Well, you didn't go into this job not to help people. You 
went into this business to make a difference, to save people's 
lives and help them, but when it comes to prescribing or 
recommending treatments, you can only do your job--everyone can 
only do their job if, effectively if patients don't face those 
insurmountable financial barriers, and for many seniors, there 
are barriers for each and every one of their prescriptions. 
Think about Ms. Milner. Again, according to AARP, the average 
older American takes roughly five prescriptions a month, 
typically on a chronic basis to treat conditions like we have 
talked about, cancer, asthma, COPD, diabetes, heart disease, 
and others.
    Shockingly, the average annual list price for one brand 
name drug used on a chronic basis was over $6,600 in 2020, 
which is more than one-third of the average senior's Social 
Security retirement benefit. Think about that. More than one-
third of your yearly income just spent on one brand name 
prescription drug. Even existing Medicare Part D coverage can't 
always make that affordable for most seniors.
    Dr. Madison, I am going to turn to you. As a clinical 
pharmacist, I know how deeply and passionately you care about 
this. You have been involved in assessing both patients health 
needs and their medication evaluation, as you have spoken to, 
and their management, so can you tell us about the times when 
you have recommended medications to your patients that you know 
that are appropriate and effective, the best medication, but 
had to instead suggest something perhaps less effective or less 
beneficial because the patient simply couldn't afford the 
choice.
    Dr. Madison. Absolutely. One of the first things that I was 
thinking of when I was thinking of this question was, you know, 
our lovely advocate over here, Ms. Milner, and really the high 
cost of diabetes. There have been amazing innovations in 
diabetes therapeutics over the past, really just the past five 
years, and seeing a lot of these newer medications that are 
injectable therapies that are taken maybe once a day, but they 
are quite expensive, so you know, knowing that someone could 
benefit from an injectable long acting medication and not being 
able to receive it, having to use things like oral medications, 
oral medications that are taken multiple times a day, which we 
know directly impacts an individual's ability to remember 
taking their medication, we are talking about seniors--exactly.
    The more we can simplify their regimen, the more likely 
they are to get the most benefit from their therapy, and so, 
many times we have had to recommend a generic or something that 
is more likely to impact their kidneys or their bones or their 
eyesight. You know, I just, I was so touched by Ms. Milner's 
testimony, and I see so many of the patients that I have worked 
with over the years in her, and even just thinking about my own 
grandmother who passed during the beginning of the pandemic and 
thinking about her care and, you know, having dementia and not 
understanding, you know, all of the different things that she 
needed and caregiving and making those decisions when you get 
to that twilight of our lives, and it is really impactful, you 
know, the work that you are doing, the work of Congress, and I 
am so excited to see the improvement in quality of life that 
our seniors are going to have, and not just that, but our 
economy, because think about it, if people don't have to worry 
about affording their medications, they are more likely to 
engage in doing and going out and spending money and being 
consumers, so it is not just about the amount of life, but the 
quality of life that our seniors can live.
    Senator Rosen. You want the best patient outcome----
    Dr. Madison. Absolutely.
    Senator Rosen [continuing]. and you answered some of my 
other questions, but you didn't answer, I want you to talk more 
about the hoops that you might have to go through as a medical 
provider if you know that there is a good medication out there 
that is really going to make a difference, to try to get that 
financial assistance for your patients. Tell me about that.
    Dr. Madison. There is a couple of different things that we 
can do. Obviously, there are certain manufacturers that have 
copay assistance cards, so that is very helpful, but not every 
pharmacy has the time to be able to go through and do that and 
so that can be a little bit challenging, and then also, you 
know, if you are having an issue with receiving your 
medication, there may be some things about, you know, delivery. 
As I mentioned before, 20 percent of prescriptions are 
abandoned usually because they can't access them, or they can't 
afford them, and so if transportation is an issue, being able 
to deliver the medication to the patient's home is extremely 
impactful, and then not being able to provide them with the 
best medication has other possible side effects, so it is not 
as good, so the medical condition that they have may not be 
treated to the best of its ability, but then they may also be 
more likely to experience side effects from the medication as 
well, and so those are the things that we really want to try to 
avoid.
    Unfortunately, the hoops that we have to jump through are 
prior authorizations, things not being on a formulary, going 
and negotiating with the managed care offices because they put 
certain things on because they got it because there was two or 
three other medications that that manufacturer also made and 
they made a bundle and they said, okay, we are going to put all 
of these medications on the formulary, and unfortunately, the 
rhyme and reason to that is not something that the average 
senior understands. They just understand that they are not able 
to access the best medication, and it is really hard----
    Senator Rosen [continuing]. time jumping through hoops when 
you could be actually dealing with patients, and so that takes 
away your time to be able to do direct care.
    Dr. Madison. Yes, absolutely.
    Senator Rosen. I have one more question for you. Well, we 
have a bunch more to go through, but I was a caregiver for my 
parents and in-laws as they aged, so I understand that aspect, 
but have you seen the high cost of prescription drugs? How does 
it impact the caregivers who take care of your patients? Maybe 
if people aren't able to get the best medication or they are 
having to ration or whatever you are seeing.
    Dr. Madison. Well, we are seeing people consolidate 
households. We are seeing people dipping into their savings, if 
they even have savings. You know, if they are living paycheck 
to paycheck, they are going to social services.
    They are accessing food pantries, they are accessing 
assistance programs, you know, meals on wheels, dining with 
dignity, all these different things that, you know, I am seeing 
people that ordinarily wouldn't access those services or are 
coming but are reluctant because they feel embarrassed, or they 
feel like they don't understand how they got into this 
situation, and they are so thankful when they come and receive 
donations, clothing. You know, some people lost their jobs 
during the pandemic and lost everything, and so the caregivers 
of people who have chronic medical conditions, they need a 
respite as well, and so you see a lot of stress, anxiety, 
depression in those caregivers because they are internalizing 
the hurt and the pain that the people that they are taking care 
of are experiencing.
    Senator Rosen. Giving people their medication at affordable 
prices creates a better community for everyone----
    Dr. Madison. It impacts so many things.
    Senator Rosen [continuing]. that is the bottom line right 
there. Well, we are going to talk a little bit specifically 
about diabetes now for a minute, because currently more than 
375,000 Nevada seniors receive prescription drug coverage 
through Medicare Part D, and over a quarter of them, more than 
93,000 Nevada seniors, have diabetes, so across the U.S. in 
2020, Part D enrollees spent a total of $1 billion, $1 billion 
on out-of-pocket on insulin. That is an average of $54 per 
insulin prescription. For many Nevada seniors living on that 
fixed income, $54 for each insulin prescription, we know, we 
know it is just not affordable.
    Despite being a lifesaving drug, many seniors, including as 
we have heard today, you, Ms. Milner, are forced to sometimes 
ration your insulin or you simply don't buy it at all, but 
again, we are proud to report helps on the way thanks to the 
Inflation Reduction Act.
    Beginning next year, it will be here before we know it, the 
cost of insulin will be capped at $35 a month for Medicare 
beneficiaries, not just here, across the country, and so $35 
insulin.
    I know you take 27 medications, but just tell me how that 
feels--how that feels to you, just that one change.
    Ms. Milner. That one change makes me feel so relieved 
because as I stated, the--as Dr. Madison understands, it isn't 
on the formulary. I had to go through many hoops, hurdles in 
order to have my physicians do the prior authorizations, 
dealing with the MCOs who in prior authorization, departments 
that sometimes don't understand how important it is because 
other medications, insulins can make you very ill, as it did 
with me, and so having that relief is just a burden that I feel 
is just--I can breathe. It is gone.
    Senator Rosen. It is going to help the rest of your medical 
condition just to have that stress removed.
    Ms. Milner [continuing]. and that is because when your 
glucose is not right, nothing is right. Nothing feels good. It 
is the worst feeling in the world, so it is a total relief, 
just that drug alone, knowing that $35, oh, my God. I mean, I 
am so--again, the only word I can use is grateful, and 
regardless of how ill I am, for me, the solution is to wake up 
every day and be grateful for all that I do have, for the 
people that have helped me, the people who have sacrificed for 
me. I am grateful, and I am grateful for you and you and you. 
For everything, I am grateful.
    Senator Rosen. We are grateful for you too and we are----
    Ms. Milner. It is a godsend.
    Senator Rosen. We are proud to do this work, and so I am 
going to turn over to Ms. Moore in AARP, because this is just 
one story. I probably could have a thousand people here, and 
you would hear a similar story about their struggles, about the 
relief they will feel when just this one burden is off of their 
mind, and you represent over 320,000 Nevada seniors. I know we 
are hearing from one, but you can speak on behalf of them. What 
do you think--if you just want to think about the emotional 
relief or what that might mean to people, just give your 
impression.
    If you can consolidate 325,000 seniors into a couple of 
sentences, what do you think just that one change means?
    Ms. Moore. Like Ms. Milner, she is one of many stories. We 
know that many families across Nevada and across the country 
really are struggling with the outrageous prices of insulin, 
and really people needed to stay alive and healthy.
    That is the bottom line. It is just one tragic example of 
the larger problem, we have heard from Dr. Madison, of the drug 
industry that affects so many different medications, and 
thankfully, the $35 monthly cap for insulin in Medicare that 
AARP supported will affect very soon.
    Like you said, 2023 is right around the corner and Part D 
plans will require to offer this copay a month even before the 
enrollee meets the deductible for the year, so people will see 
the co-pay changes at the beginning of the year, and AARP would 
welcome the chance to extend this cap to others beyond Medicare 
as well, whether it be at State or Federal level.
    AARP offices across the U.S. have been active in the State 
Legislatures and across the country, as I said, for over the 
past few years, to pass insulin co-pays in State laws that 
would apply to private insurance, so AARP will keep fighting 
for Americans 50 plus, and for all, so that they can afford 
their medications.
    Senator Rosen. Thank you. Mr. Klein, I know you work with 
so many seniors and you are going to be able to maybe put some 
of your financial resources or some of the magic that you do to 
help those thousands of seniors every year. Give me a little, 
from your perspective, $35 insulin, how is it going to help 
your team, help others, and what is the impact on what you do?
    Mr. Klein. It is a huge boost. First of all, it is going to 
be a boost to the team. Folks who work in the trenches take 
this seriously. It weighs on them every day. Every time 
somebody comes through the door, a patient comes through the 
door who needs help, and you don't have a resource, it is a 
failure in the minds of the people who are attempting to take 
care of them and help them. This is the cavalry coming. First 
of all, it is hope, and hope is really important in this 
population. It is almost more important than the immediate--to 
know that something is coming----
    Senator Rosen. Give you a boost.
    Mr. Klein. It gives you a boost. It tells you that there is 
an opportunity to impact it. Second, for this particular 
population, our staff are constantly looking for resources, 
attempting to find other not for profits, who might have a 
medication program that we could pair with, well if we can 
lower the cost, can we fill in the blank to help them get 
coverage for the short period of time that might be the bridge 
between programs or to wait for something larger to come along, 
so this is major news. It is major news not only for the 
senior, but importantly, it is major news for caregivers who 
have really been struggling with this and who take it home with 
them every night.
    Senator Rosen. Will be able to put those resources to some 
other benefit. Dr. Madison, from a medical perspective, we know 
the impact it is going to have, so just tell us the impact if 
people take their medications regularly on time, at the right 
dose. Tell me how you are feeling about that.
    Dr. Madison. Yes. The three Rs, right. Right drug, right 
time, and the right way.
    Senator Rosen. See, there you go. I didn't even----
    Dr. Madison. Tell people the three Rs. I mean, it is 
incredible, right. Obviously, you know, we are talking a lot 
about diabetes because it impacts so many individuals, but 
really, these concepts and these, you know, these interventions 
go across any chronic medical condition, and so for me, my 
biggest thing when I talk to my patients is, do you feel better 
or worse or the same?
    If it is the same or worse, then I need to think what is 
going on, is the medication that you are taking appropriate? If 
it is not, how can we fix it? Having the ability to be able to 
take your medication at the right time and the right way and 
the way that it was intended by your health care professional, 
by your physician, by your nurse practitioner, by your 
physician assistant, right, it is so critical because when you 
start getting between that relationship, now you have messed 
things up, and the intended purpose of that medication goes 
away because now the patient can no longer be adherent because 
the medication only works if you can take it and you can't take 
it if you don't afford it.
    This is incredible. I think just looking at, you know, 
chronic disease management, there are so many ripple effects 
that will go toward this. If you are able to be healthier 
because you are able to take your medications, you are going to 
be a more productive member of society.
    You are going to be able to do more things. You may start a 
small business. You--there are so many different things that 
you could do. As a senior, you may be able to take care of your 
grandkids that you maybe weren't able to before, and that could 
help the family, and then you can--then you can potentially 
help your children so that they don't have the burden of 
childcare. There is so many ripple effects that this can help 
with just by simply making sure people can take their 
medication.
    Senator Rosen. Thank you. Well, we are going to talk about 
some other prescription drugs now because this is just one of 
them, the first one that is going to hit right away, no 
deductible. It is going to be so impactful, but we are going to 
put caps on price increases for drugs under Part D, because we 
have discussed today, Nevada's seniors, including those with 
Medicare Part D insurance coverage, well, it goes without 
saying, they are paying far too much for their prescription 
drugs, and drug manufacturers have continued to raise prices at 
unsustainable rates, and so, in fact, according to a recent 
Kaiser Family Foundation study, half, half of all Part D 
covered drugs had price increases greater and the rate of 
inflation in 2020, greater than the rate of inflation in 2020. 
This is just unacceptable, and it is one of the reasons why 
Democrats in Congress, why we did pass the Inflation Reduction 
Act, and so we are going to talk a little bit more about the 
law.
    Starting next year, this new law will require manufacturers 
that raise the prices of drugs faster than inflation to pay 
rebates back to Medicare. This way, drug companies will either 
need to keep prices affordable in line with actual increases in 
the cost to make them or have to pay a rebate to Medicare.
    Either way, seniors win. I want seniors across Nevada and 
across the country to hear us loud and clear. This new law will 
bring relief to seniors by lowering their expensive drug costs. 
Ms. Milner, I know we are going to keep going around the table, 
but you take a lot of medications, and so you have had some of 
them that have gone up and up and up, and so I am going to ask 
you, from your perspective, not just the cost, we know they are 
unaffordable, but what is the emotional burden when you see the 
drug go up so high year after year?
    Ms. Milner. It is an insurmountable emotional burden, 
because as you have all stated, it is a domino effect. It 
affects not just me, but my family. I think, wow, I have got 
three grandsons. I want to still be able to get down on the 
floor and play racecars with my grandsons, and I can't do that 
if I can't afford my drugs.
    However, I have noticed, and I want to say, since I am on 
the right diabetes medication, I can afford to eat right, and 
when I can afford to eat right, God bless me, I take less 
diabetes medication, less insulin, and it makes me feel so good 
because then I have more energy. I am more cognizant.
    I can just do better all the way around, so it means the 
world to me. It really does. I mean, I think that if we have 
more people who could help others who are in this situation to 
advocate for themselves, they would be a whole lot healthier. I 
mean, just understanding that, yes, you have to take your 
medication, but you also have to eat right.
    Senator Rosen. That costs money, so now you spend less 
money on your medication, you can eat healthier----
    Ms. Milner. I can afford to buy the vegetables I need.
    Senator Rosen. That is right.
    Ms. Milner. Eat right and keep my glucose at a level that 
it should be, and it really matters.
    Senator Rosen. Sounds fantastic. Well, Ms. Moore, I keep 
turning to you because you get to represent all the seniors in 
Nevada, and so on a bigger note, what do you hear from Nevada 
AARP members about the drug manufacturers just raising these 
highly inflated costs well over the rate of inflation. What do 
you hear from your AARP members about this?
    Ms. Moore. Senator Rosen, the rising prices of prescription 
drug prices, that is the number one. One of the things that we 
hear most from our members, and it is no secret, so you are--we 
hear your stories every day.
    In the years leading up to the passage of the Inflation 
Reduction Act, 37,724 Nevadans signed AARP petitions calling on 
Congress to take action to reduce drug prices. I know that the 
Senator got many of her emails, letters, and--just about every 
day. We were relentless. It was truly tragic when an older 
person, fixed income, has to choose, like you said, between 
essentials like food and rent and the medications that they 
need to keep themselves healthy. It is a ripple effect, and 
when the prices of those drugs are increasing and often much 
higher than the rate of inflation, there is simply no way for 
these seniors to keep up. You just can't. It is also important 
to keep in mind that these increases are at the top of 
sometimes decades of annual price increases, and those price 
increases add up over time.
    Senator Rosen. Thank you. I am going to--I want to say I am 
grateful for the AARP partnership. Those e-mails helped, and 
those letters and those calls and all the conversations we had. 
Honestly, I carry those stories with me. I retell those 
stories. I am grateful for that partnership, and Mr. Klein, I 
guess the same thing to you, because you see different. We have 
a patient. You talk about all the seniors. You have a lot of 
boots on the ground. Again, we are going to try to get those--
they may go up, but only to the rate of inflation.
    Mr. Klein. Cost escalation for people on fixed incomes, and 
many seniors are just that, people on fixed incomes, and we 
can't forget that many of our seniors are taking care of even 
older parents, taking care of a spouse, taking care of a child, 
and frequently taking care of grandchildren in today's world, 
so you take someone who is on a fixed income, who is also 
caregiving for a wider group, and then you apply cost 
escalations that force them to make choices, and those choices 
are serious. They are not just choices about themselves and 
what they do for themselves, but they are in effect choices of 
what they make for their entire caregiving unit.
    At the end of the day, some people end up in nursing homes 
when that cost gets to be too great for them to bear. The 
consequences of high escalation and pharmacy costs really bring 
those costs on the bear, so this is again, this is, as I 
mentioned earlier, this really is in many respects the cavalry.
    This is putting a lid on just how much burden some of these 
families will have to absorb, and also, we think it will also 
put a lid on some of the other problems that these choices 
make, so you know, to Regina's comment about nutrition, when 
you have to make a choice between good nutrition and 
medication, you can't win in that choice.
    Senator Rosen. That is right.
    Mr. Klein. Putting a lid on it, creating certainty, is 
really critical, and I think this has been an amazing and 
important accomplishment.
    Senator Rosen. Well, and I think to your point, whether it 
is a multigenerational household like Ms. Milner's, or whether 
they are the seniors who are living independently on their own, 
we want to keep them there. We want to keep them from moving, 
if we can, to a nursing home or some of those, and keep them 
either independent or with their family where it is much 
better.
    I am going to just ask you, doctor, as a provider--now if 
again, you are looking to provide a medication or multiple 
medication, so knowing that this isn't going to go up 
exponentially, how do you feel as a provider when you walk in 
the room and you are going to have to talk to a patient?
    Dr. Madison. Incredible. That is the best way to say it, 
incredible.
    You know, when you look at a patient's face when you tell 
them the cost of a medication and you see sort of the life 
drain from their face and the emotion change, it is 
devastating, and to know that these prices will be capped and 
that now they don't have to make those difficult choices 
between their basic needs being met and their life saving 
medications is just incredible. I can't think of a better word 
other than that to say it and really just----
    Senator Rosen It will remove stress and burden from 
providers because you don't want to go in with the 
disappointing news, so that is going to make your ability to 
care for patients so much better.
    Dr. Madison. Not to mention the fact that as a provider, 
you take those stories home too.
    Senator Rosen. Right.
    Dr. Madison. I think it helps everyone. It is not--you 
know, I think about many times where I just think about just 
recently where I was helping out at an advocacy agency, and we 
were giving out food to seniors, and a woman drove up and we 
were walking over to start helping out, and she was turned away 
because they were closed at that time, but because of a 
language barrier, she didn't realize that they were just closed 
for lunch and not closed for good, and so she had asked me 
earlier, like, I was walking over in the parking lot, and she 
asked me where to go, and so when I told her, I knew she was 
there for the food assistance, and so as I saw her about to 
leave, I noticed she didn't have the food in her hands, and I 
said, ma'am, you know, is there anything else I can help you 
with? She said, oh, no, no, no, they said that they are closed, 
and I said, oh, they are just closed for lunch, can you wait 
like another like maybe 20 minutes, and they will open up 
again, and she said, oh, yes, thank you, thank you, so very 
like sense of relief, and then about an hour later, we went 
back to help give out the food and she came back.
    I was so happy to see her because, I mean, it was just the 
difference of better communication, but I was just thinking 
like how many other people in her house that she was feeding 
that were depending on that food.
    Senator Rosen. The ripple positive effects in advocating 
for people, and so I am going to--it leads me directly into my 
next question, which is really advocating for patients in need, 
and of course, all of you are advocates, but Mr. Klein, I am so 
incredibly proud of the work that Nevada Senior Services does 
to help educate, advocate for seniors who need help finding 
health care, finding resources, navigating complex agencies, 
trying to do those home modifications sometimes you may need in 
a bathtub or bathroom getting, you know, whatever those things 
are so you can age safely in place, and services are just so 
important.
    You know, Nevada senior population is growing so quickly. 
Between 2011 and 2018, Nevada's population, age 65 and older, 
increased by 40 percent. I think that puts us in one of the 
faster growing States, I might say, and the population of 
Nevadans aged 85 and older increased by 25 percent. That is 
double the national rate, and so one of the programs you do, 
one that particularly stands out to me is your comprehensive 
geriatric assessment program, and you bring together a team of 
medical and social service professionals to examine that 
patient's overall well-being, and that, of course, includes 
prescription medication review and management, so can you just 
talk to us a little bit or walk us through the comprehensive 
geriatric assessment process, and in particular, well, you are 
going to have hopefully have a little bit of help with the 
Inflation Reduction Act, but how you help them navigate the 
cost of the prescription drugs, which is why we are here.
    Mr. Klein. Thank you. Very quick, we are very proud of that 
program. It was a first in Nevada. I would love to say it was 
the first in America, but I actually opened one of these in 
1972 in Philadelphia, which was actually the idea of one of our 
medical directors at a hospital I was working at. I have 
carried it with me.
    Senator Rosen. That is a good thing to carry.
    Mr. Klein. It was, and when we created it in Nevada, we 
created it as a collaboration, so we have a board certified 
physician in geriatrics who comes to us from Touro. We have 
pharmacy--former geriatric pharmacy help who comes to us from 
Rosemont.
    We have our own geriatric nurses, our social workers, 
occupational therapy that also comes from Touro, and that team 
gets together and spends about three hours examining the 
records and the history of the person who is coming to them, 
usually with their family caregiver, and then doing an in-
person exam of the patient to try to get at the root of all the 
complex problems people have, some of which are purely medical, 
but most of which are combinations of complex issues that 
include family caregiving issues and always medication issues.
    Senator Rosen. Right.
    Mr. Klein. It is not unusual for us to find people on drugs 
that they shouldn't be on in the first place that are 
contraindicated for seniors.
    It happens all the time, and we are in a position then to 
go back to their physicians and their primary care physicians 
and say, well, you might want to think about some alternatives, 
and it is not unlikely that we get that story of the person 
that says sheepishly, well, I haven't been taking this one or 
that one because, and inevitably because it is dollars, and so 
one of the people in the room is a navigator or a social worker 
who has got real skills in navigating where opportunities for 
reimbursement and other financial supports are, and they go to 
work. Nobody leaves there without their medications.
    Senator Rosen. Right.
    Mr. Klein. Nobody leaves there without a resource for 
medications. Nobody leaves there without the opportunity to get 
follow-up from the team, and so it works well, and it works as 
a family endeavor of not only the whole health care team, but 
the family caregiver in conjunction with the person who is 
receiving services.
    Senator Rosen. That seems like this great overall 
comprehensive project and group, and I think that is what gives 
you so much success. We are going to move on to our last 
question and something that we have been thinking about--well, 
we always think about this, but because of COVID-19, it has 
really been on the forefront of everyone's mind, which is the 
vaccinations, and of course, for seniors, there is quite a few 
vaccinations that they can take to help improve their lives and 
keep them disease free, and so free vaccinations for seniors on 
Medicare Part D. Dr. Madison, many of the senior patients you 
see, I hope they have the Part D plans and therefore almost 
half a million Medicare eligible individuals in Nevada, 15 
percent of our population, actually has a Part D, and in rural 
counties, have a higher percentage per capita of Medicare 
beneficiaries with Mineral, Nye, and Douglas counties' Medicare 
eligible population is currently over 30 percent, 30 percent of 
their total populations.
    Thousands of Nevada seniors who could benefit, again, from 
reduced health care costs from the Inflation Reduction Act 
because we are going to establish zero cost sharing for 
vaccines for seniors on Medicare Part D starting in January, 
zero cost sharing.
    That is what the Inflation Reduction Act is doing. It is an 
especially important relief. Some of these diseases, I know 
there is pneumonia and shingles. You could probably tell me all 
the ones there are, but some of these vaccines like shingles, 
we talked about the price, are so expensive.
    Can you tell me, Dr. Madison, how you think the Inflation 
Reduction Act's free vaccine provisions, how that is going to 
make a difference for the population that you serve, and what 
are the health care consequences of seniors foregoing these 
vaccines?
    Dr. Madison. First and foremost, I want to say public 
health is obviously my focus, and you know, vaccinations are 
literally the single most effective public health intervention 
in modern medicine, right. That is how we were able to get rid 
of smallpox, and up until about a month ago, polio, right, and 
so it is so important for us to be able to provide these 
preventative care measures, in particular to seniors, because 
these vaccine preventable diseases can be devastating to 
seniors.
    When we think about hospitalizations, especially when we 
think about things like influenza, that 36,000 individuals per 
year being hospitalized and potentially passing away is usually 
from the secondary bacterial pneumonia that they get after 
getting the flu, so when we can provide things like 
pneumococcal vaccination, influenza vaccination, it helps to 
not only keep those seniors healthy, but out of the hospital, 
which again, creates more health care cost and more burden on 
themselves and their families and their communities, so this is 
extraordinary that they will be able to provide these 
vaccinations at no cost to seniors, and I just think about 
individuals who have suffered from shingles. If anybody has 
known anyone who has had shingles, it is something I would not 
wish on my worst enemy, and now that the ACIP, which is the 
Advisory Committee on Immunization Practices, has now 
recommended it now all the way down to the age of 19, there are 
now people who can get it that have autoimmune diseases that 
are more at risk because their immune system is suppressed, and 
it puts them more at risk for getting things like shingles, so 
extraordinary, incredible.
    Can't think of anymore, you know, fantastical words that I 
can use, but just so great that we can provide these 
vaccinations, lifesaving, life changing vaccinations to 
seniors.
    Senator Rosen. Mr. Kline, all these vaccinations are going 
to be free, so how are you going to be sure that you get the 
word out to all the seniors, even more working with your 
partner agencies, every senior in Nevada that who wants one can 
get one free of charge due to the Inflation Reduction Act.
    Mr. Klein. Advocacy, advocacy, advocacy. We are really 
proud. We have been running vaccine clinics for as long as I 
can remember. It started with flu and pneumonia and the latest 
flu vaccine comes out, the latest pneumonia vaccine, we try to 
get the word out into the community.
    Importantly, we work with a network of other not for 
profit, so organizations like Helping Hands, so folks who 
deliver food banks, who are food pantries, we get the word out, 
we collaborate. We try to reach the people who are hard to 
reach, those seniors who are not out about as much, and to 
encourage them to come out.
    Then we follow-up with them because they can't get all 
their shots at one time, so we have to run a second clinic and 
then we say, gee, we are really glad you got your pneumonia 
shot, but it is time you get your COVID booster, or it is time 
for you to get your flu shot, and so we have a pretty 
aggressive, in a most positive way, loving way we can make it, 
a line of encouragement with our partners all over Southern 
Nevada, and then we run programs, and we run--we provide food. 
We provide education. We try to do things that encourage folks 
who otherwise can't get out, and those who can't get out, who 
are homebound, we send somebody to them.
    Senator Rosen. That is fantastic. You are going to get the 
last question because speaking of advocacy, AARP, really, you 
are the big umbrella organization looking at all of these 
things, and so how are you going to help everyone here today be 
sure that the word gets out to every senior in Nevada, rural 
and urban, regardless of the language that they speak, that 
they have access to free vaccines starting next year?
    Ms. Moore. We have a saying at AARP that says what we do 
for one, we do for all. It is our founder's--I feel it is my 
favorite quote from her. The free vaccines under Medicare, as 
Dr. Madison said, there is only one word for it, incredible. 
Incredible and very soon, so for this benefit and all benefits 
of this historic law, we are certainly going to plan major 
public education and outreach and push various articles. We 
have our comms director here with us today, ensuring that folks 
know where to go for the best information, and we will be 
producing videos, we will be doing lots on our website.
    That is--you know, it is not only for our members, but 
really anyone can access that information. We want our members 
and the public to have a clear sense of what this--what is 
expected and what is to come in this new law, and we welcome 
the work of our Members of Congress.
    You know, we work really well with you, Senator Rosen, and 
we know that that will continue, or really any other 
stakeholders we work with. Jeff, very well, and other not for 
profits, nonprofits, and community partners because we want to 
keep a focus on this issue.
    We want to help educate the public about the prescription 
drug provision in the Inflation Reduction Act, so our work is 
not done.
    Senator Rosen. Well, and you have a partner in me, and I 
know that you have a partner with everyone here, and of course, 
the rest of the Democratic Federal delegation, and so I can't 
thank you all enough for being here, for contributing your 
time, your expertise, your emotions, your passion, all of it. 
It means so much to so many, and of course, I want to thank the 
College of Southern Nevada for giving us this wonderful space 
to do this, and because you know what, in a country as 
prosperous as ours, we should do better. We should always do 
better, especially for our seniors, and no senior, as we have 
spoken about, should be forced to choose between paying for 
life saving medication or keeping their lights on. No senior 
should have to choose between affording their insulin or 
putting food on the table, and no senior should be expected to 
spend nearly all of their Social Security check on the 
prescription drugs they need just to live their everyday lives.
    Unfortunately, as our witnesses have testified today, this 
is far too often the case in Nevada and across the country. We 
can and we must do better, and now, thanks to action in 
Congress, we are going to do better, and I am proud again to 
say that Democrats in Congress, well, we have been listening to 
Nevadans and to the American people.
    We have taken your stories, these stories here today and 
those you represent back to Washington, and we enacted bold, 
historic legislation in the Inflation Reduction Act, 
legislation I am proud to have voted for that will finally 
lower prescription drug costs, and as we have heard today, I am 
going to reiterate all of this. This new law will do just this, 
finally, finally allow Medicare to negotiate for the best price 
of prescription drugs.
    Finally cap seniors' Part D out of pocket spending at 
$2,000 per year. Finally, cap seniors' insulin costs at $35 per 
month. Finally, cap prescription drug price increases to no 
greater than the rate of inflation, and finally, increase 
Medicare subsidies for lower income Americans.
    We are going to do even a little bit more. We are going to 
ensure that all seniors receive all their vaccines at $0 cost 
sharing, free, free, and we are going to reduce burdens on 
those health care providers, like Dr. Madison and others, and 
the caregivers, those angels and our family and those that work 
with us, by delivering lower costs for seniors across the 
board, and I am so proud of the work my Democratic colleagues 
and I have done to lower these costs for seniors to protect and 
to expand Medicare, but I want everyone to know this is just 
the beginning.
    Moving forward, I will continue to fight to protect 
Medicare, to reduce health care and prescription drug costs for 
Nevada's seniors, and I will continue to work with all my 
colleagues to make Medicare even stronger for years to come.
    Now our closing business, if any Senators not in attendance 
today have additional questions for these witnesses, any 
statements you would like to add for the record, the hearing 
record will be kept open for seven days until next Tuesday, 
August 30th.
    With that, thank you all again for participating, and this 
concludes today's hearing.
    [Whereupon, at 3:48 p.m., the hearing was adjourned.]



      
      
      
      
      
      
      
      
      
      
      
      
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                                APPENDIX

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                      Prepared Witness Statements

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