[Congressional Record Volume 165, Number 77 (Thursday, May 9, 2019)]
[House]
[Pages H3658-H3661]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                          PHARMACY DRUG PRICES

  The SPEAKER pro tempore. Under the Speaker's announced policy of 
January 3, 2019, the gentleman from Georgia (Mr. Carter) is recognized 
for 60 minutes as the designee of the minority leader.


                             General Leave

  Mr. CARTER of Georgia. Madam Speaker, I ask unanimous consent that 
all Members may have 5 legislative days in which to revise and extend 
their remarks and include extraneous material on the subject matter of 
my Special Order tonight.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from Georgia?
  There was no objection.
  Mr. CARTER of Georgia. Madam Speaker, I am grateful for the time 
tonight to talk about a very important subject. As many Members know, 
currently, I am the only pharmacist serving in Congress, and that is 
something I take very seriously.
  Two of the things that I really wanted to concentrate on when I 
became a Member of Congress, among many things, but two of the main 
things were, first of all, prescription drug pricing--that is one of 
the things that we want to talk about here tonight--and the other thing 
that I wanted to concentrate on was the opioid epidemic. We have been 
very successful here in Congress in addressing that issue.
  Tonight I want to talk about prescription drug pricing because I have 
witnessed it. I have witnessed what I would describe as truly a crisis.
  After 30 years of practicing pharmacy, I have seen families struggle 
to pay for their medications. I have seen senior citizens at the 
counter across from me try to make a decision between buying medication 
and buying groceries. I have seen mothers literally in tears because 
they couldn't afford the medication for their children.
  When I came up to Washington, that was one of the things I wanted to 
concentrate on. We are very fortunate we have a President and 
administration who are focused on this issue as well and have done some 
outstanding things. Two of those things that are being proposed by the 
administration right now I want to talk about tonight, but the main 
thing I want to talk about is the prescription drug chain.
  Just earlier today, we had a hearing in the Energy and Commerce 
Committee, in the Health Subcommittee that I serve on, where we had 
representatives from the pharmaceutical manufacturers and from the 
PBMs, the pharmacy benefit managers, pointing fingers at each other and 
blaming each other for the problem.

                              {time}  1900

  I have to tell you, in full disclosure, I am a big fan of the 
pharmaceutical manufacturers. What I have seen over my years of 
pharmacy practice has been nothing short of phenomenal.
  When I first started practicing pharmacy in the early 1980s, I can 
remember a time when, if you needed an antibiotic, you had to take 40 
tetracycline. You had to take four a day for 10 days. Now you can take 
an antibiotic or get a shot in one day and be cured of some of the 
things that we were treating back there in 1980 with a 10-day supply.
  I have seen illnesses such as hepatitis C--and hepatitis C, when I 
first started practicing pharmacy, was pretty much a death warrant. If 
you were diagnosed with hepatitis C, you were probably going to die.
  Through the research and development of the pharmaceutical 
manufacturers, I have seen them come up with medication so that we can 
now treat hepatitis C. That is phenomenal. We can cure it with a pill, 
and it is because of the research and development that has been done 
through our pharmaceutical manufacturers and through the National 
Institutes of Health that we have reached this point.
  However, the price of those medications, in many cases, makes it 
inaccessible for people. If you have to pay $85,000 for a medication to 
treat hepatitis C, for many people, that is just simply not accessible. 
If that medication is not accessible, it does you no good whatsoever.
  I have called on the pharmaceutical manufacturers to do their part as 
well. They are not without responsibility here, and I think they 
understand that.
  Tonight, what I want to concentrate on are the PBMs, the pharmacy 
benefit managers, the middlemen, if you will. If you look at their 
mission statement, they will tell you their mission is to lower drug 
costs.
  My questions to you would be: How is that working out? If that is 
working out, if they are achieving their mission, why are we here? Why 
are we here tonight talking about this, the high prescription drug 
costs?
  I submit to you that they bring no value whatsoever to the healthcare 
system.
  Madam Speaker, I am very blessed tonight to have a number of speakers 
here with us to share their expertise, and I want to hear from some of 
them right now.
  I want to begin with the gentleman from Kansas, Representative Roger 
Marshall, who also is a physician, was a hospital administrator, and 
knows and understands this system.
  Madam Speaker, I yield to the gentleman from Kansas (Mr. Marshall).
  Mr. MARSHALL. Madam Speaker, I thank my colleague for yielding.
  Madam Speaker, I rise today in support of the Trump administration's 
rule that will modernize Medicare part D and, as a result, lower drug 
prices, reduce out-of-pocket expenses for America's seniors, and make 
critical fixes to our systems that will help our local pharmacies.
  Across Kansas, there are 506 chain drugstores and 253 independent 
community pharmacists. These pharmacists are honest, hardworking men 
and women who often go above and beyond to ensure that patients know 
how to manage their medications.
  I have heard their stories, and they all share the same frustration: 
direct and indirect remuneration, or DIR, fees.
  In many instances in rural America, the only healthcare professionals 
left standing are my good friends and colleagues from the noble 
pharmacy profession, and these DIR fees are running them out of town.
  The increase of DIR fees over the last several years has raised out-
of-pocket costs for our seniors and put our pharmacies at financial 
risk, often operating in negative margins.
  Far too regularly, pharmacy benefit managers, or PBMs, collect DIR 
fees from pharmacies months and months after claims. It is completely 
unpredictable and unfair, and the benefits all go into the pockets of 
the pharmacy benefit managers.
  Shame on them for doing this, but not anymore. This proposed rule 
will guarantee predictability by helping standardize the process and 
end the disparity between pharmacists, patients, and PBMs.
  The Centers for Medicare and Medicaid Services estimated that seniors 
will save up to $9 billion--$9 billion--over the next 10 years, and the 
Federal Government will save nearly $17 billion over that same 
timeframe.
  I appreciate President Trump and his administration for addressing 
this concern and providing commonsense, financially responsible 
solutions.
  It is my hope and the hope of pharmacists across the country that 
this rule will be finalized quickly so that it can go into effect next 
year.
  I would like to recognize my colleague, pharmacist Buddy Carter, who 
may know this issue better than any of us, as our only pharmacist in 
Congress.
  I thank my colleagues Dr. Phil Roe, Morgan Griffith, and Peter Welch 
for leading on this issue and bringing it front and center for both the 
Doctors Caucus and the Energy and Commerce Committee members.
  Mr. CARTER of Georgia. Madam Speaker, I thank the gentleman for his 
keen insight on this subject. It is very important, and I appreciate 
his expertise.
  Madam Speaker, what the gentleman from Kansas was speaking about are 
two proposals that are before CMS right now.
  One proposal would do away with DIR fees. Now, let's make sure we 
understand that DIR stands for direct and indirect remuneration. This 
is when the PBMs go back months later--in some cases, years later--and 
recoup, or claw back, reimbursements for what they have already sent to 
the pharmacies.
  You can imagine what kind of impact this would have on a business. 
There is

[[Page H3659]]

no sustainable business model out there that can absorb that.
  I get texts all the time from small pharmacy chains that are telling 
me: I just got a bill from the PBM. Last year, my total DIR fees were 
$500,000, a half million dollars.

  That is money they have already paid taxes on, but they are clawing 
it back. They are taking it back.
  CMS has proposed that that end. I am in support of that, and I 
appreciate CMS doing this.
  The other proposed rule that CMS has come out with has to do with the 
rebates, or discounts, if you will, that are offered to the PBMs by the 
pharmaceutical manufacturers--not offered to them, but the PBMs demand 
them from the pharmaceutical manufacturers. What CMS is proposing is 
that all of those rebates, or discounts, if you will, be given at the 
point of sale.
  What we are trying to achieve here is to make sure that those 
rebates, that those discounts, are going where they are supposed to be 
going, and that is to the patients.
  Keep in mind, everything we are talking about here is about the 
patient. We are talking about patient care.
  My next guest speaker is also an expert in healthcare. In fact, he is 
another one of the members of our Doctors Caucus, a urologist from 
Florida, Representative Neal Dunn, who, again, has practiced in the 
healthcare field and who has seen this with his patients.
  Madam Speaker, I yield to the gentleman from Florida (Mr. Dunn).
  Mr. DUNN. Madam Speaker, I thank Representative Carter, who is a 
colleague, a friend, and a neighbor, and who also has genuine expertise 
on this subject.
  The administration recently published two rules that tackle the 
issues faced by both our Medicare beneficiaries and the pharmacies that 
serve them.
  One rule in particular, the ``Modernizing Part D and Medicare 
Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses'' 
rule, addresses pharmacy direct and indirect remuneration fee reform by 
instituting that DIR fees will be negotiated at the point of sale 
instead of the underhanded and retroactive fashion by which the plans 
and PBMs currently operate.
  Currently, pharmacies can face these clawback fees after they have 
already filled and sold a prescription for Medicare part D and Medicare 
Advantage patients.
  DIR fees have become a catchall category for pharmacy benefit 
managers to collect more overhead after prescriptions are sold.
  Pharmacies are often unaware of what they will owe, and the standards 
for these fees can be impossible to meet. As a result, many independent 
pharmacies in my district are forced to provide the drugs at below 
cost.
  Imagine that for just a moment. DIR fees are causing pharmacies to 
operate in the red, all while they are providing lifesaving medication 
to America's seniors.
  DIR fees have also led to drastic increases in out-of-pocket costs 
for our patients, which, in turn, forces seniors into the doughnut hole 
of Medicare part D even sooner.
  To protect seniors and pharmacists in my district, and as a medical 
professional, I urge CMS to finalize the language included in the rule 
that reflects the negotiated price at the point of sale.
  Mr. CARTER of Georgia. Madam Speaker, I thank Dr. Dunn for his keen 
insight on this very important subject and for his comments.
  Madam Speaker, I have a couple other comments about PBMs.
  As I mentioned earlier, if you look at their website, if you look at 
what their mission statement is, it says that they are there to lower 
drug costs. Well, that is not working out very well.
  Let me say this: I am not opposed to anybody making money. I get it. 
That is capitalism, and that is fine.
  But three PBMs control 80 percent of the market--80 percent of the 
market. Three companies control that, three PBMs. The largest PBM, in 
2016, had gross revenues that exceeded that of Ford Motor Company, 
Pfizer Pharmaceuticals, and McDonald's added together.
  Again, I am not opposed to anybody making money, but tell me how a 
company can make more than Pfizer Pharmaceuticals, McDonald's, and Ford 
Motor Company combined.
  To make matters even worse, those companies are worldwide. This PBM 
is just domestic. They are just here in America.
  Again, I am not opposed to anybody making money, but tell me the 
value they are bringing to the system. They are not bringing any value 
to the system.
  That is why I am in support of what CMS is proposing: doing away with 
the DIR fees; making sure that the rebates, the discounts, if you will, 
are given at the point of sale; and increasing transparency.
  Madam Speaker, the next speaker is a good friend, a member of the 
Georgia delegation, Congressman Rick Allen from Augusta. Rick is a 
businessman, a very successful businessman. He understands the 
challenges in business. Certainly, healthcare costs, I am sure, were 
challenges for him.

  Madam Speaker, I yield to the gentleman from Georgia (Mr. Allen).
  Mr. ALLEN. Madam Speaker, I thank Congressman Carter for yielding and 
for his efforts here this evening to shine a light on an issue that we 
all know is affecting far too many Americans.
  It is a shame to keep doing things when they don't work. Something 
has to be done.
  Madam Speaker, the rising cost of prescription drugs is causing 
significant financial burdens for millions of Americans, patients, 
seniors, and our businesses. Too often, Americans have to choose 
between much-needed prescriptions and household expenses.
  However, President Trump made it clear to the American people during 
his State of the Union Address that lowering the cost of prescription 
drugs was one of his top priorities. As we have seen throughout his 
Presidency, promises made are promises kept.
  Earlier this year, the Trump administration issued a proposal that 
would create incentives to lower list prices and reduce out-of-pocket 
spending on prescription drugs, potentially becoming the most sweeping 
change to how American drugs are priced, a much-needed change.
  By delivering discounts directly to patients at the pharmacy counter 
and bringing long-overdue transparency to a broken system, we are 
putting patients and seniors first. That is how it should be.
  It is high time to end these kickbacks to pharmacy middlemen, 
referred to as PBMs, in this process of dealing with these DIRs, which 
are putting many of those in the pharmaceutical business in my district 
out of business.
  I thank the administration, Congressman Carter, and my fellow 
colleagues this evening for their commitment to righting this ship and 
reducing drug prices for all Americans.
  Mr. CARTER of Georgia. Madam Speaker, I thank the gentleman for his 
comments, and I certainly appreciate his leadership here in the House.
  Madam Speaker, as you heard earlier from one of our speakers, CMS 
estimates that this change alone, doing away with the DIR fees--putting 
the discounts, the rebates, if you will, at the point of sale--will 
benefit the consumer, benefit the patient, and could save patients $7.1 
to $9.2 billion.

                              {time}  1915

  Now, let me tell you, that is significant. That is significant for 
those senior citizens that I was talking about earlier who are trying 
to make a decision between buying medicine and buying groceries. That 
is significant to that mother who is trying to buy the medication for 
her child. Those savings will help. Transparency will help.
  The savings are going to go much further than just this estimated 
seven to $9 billion, because as we get better transparency we will get 
lower drug prices. I am convinced of that.
  Madam Speaker, my next speaker is a gentleman who certainly 
understands this issue and has worked closely on it. He has been a 
champion on this issue. Representative Austin Scott, from Georgia, has 
gone to great lengths to study this issue. He has met with small 
pharmacies in his district. He has discussed with them the problem, and 
he understands it; and we are very, very fortunate to have him and his 
input.
  Madam Speaker, I yield to the gentleman from Georgia (Mr. Austin 
Scott).

[[Page H3660]]

  

  Mr. AUSTIN SCOTT of Georgia. Madam Speaker, I want to thank my 
colleague, Representative Carter, for his work on this. He was a small 
pharmacy owner before he got here.
  Prior to my arrival in Congress, I was actually an insurance broker 
for many years, a health insurance broker. And it always amazed me, as 
pharmacy benefit managers tried to explain their business model, that 
they actually couldn't explain their business model.
  So I rise today in support of our local pharmacies and the unique 
role that they play in serving patients. I stand here to commend the 
Centers for Medicare and Medicaid Services and the recently-proposed 
rule aimed at addressing direct and indirect remuneration, DIR, fees 
and drug rebates; rebates that don't go to the consumer, but rebates 
that go to multibillion-dollar corporations.
  I frequently make stops at local pharmacies when I am back at my home 
in Georgia, and I appreciate the services that they provide their 
customers.
  I am from a small town, and local pharmacists are a fixture in the 
community. They are the first line of defense in preventing and 
treating a customer's needs. They have known most of their customers in 
their community for many years.
  I will give you one brief example. As an insurance broker, we had 
written a contract on a business and the cards had not come in yet. And 
there is a small-town pharmacy, and then there is the big chain 
pharmacy. One of the employee's children had gotten sick.
  Guess which pharmacist was willing to work with the family to get 
them the medicine before the insurance card came in? And guess which 
pharmacist was blocked out of the plan by the pharmacy benefit 
managers? It was the same one, the local, small-town pharmacist.
  I am troubled on many of these visits, because I know how these 
community pharmacies are finding it more and more difficult to serve 
their neighbors while remaining competitive in the larger healthcare 
marketplace.
  I hear from my constituents regularly about the financial burden they 
face as drug prices continue to climb. And the price for a drug today, 
when they go to get it refilled a month from now may be totally 
different, and rarely is it lower.
  Plain and simple, we pay too much for drugs in this country. I would 
hope that it is something that we could work together in a bipartisan 
manner. President Trump has already said that he is willing to sign a 
piece of legislation to reduce the cost of pharmaceuticals in this 
country, and it is something that we should be able to come together 
and pass to help the American citizens and reduce the cost of 
healthcare for the American family.
  Most Americans assume that it is probably a pretty simple transaction 
for the pharmacist when the pharmacist purchases the drugs, even though 
they know it is a very complex transaction for them, never knowing what 
the drug is going to cost prior to going into the pharmacy.
  But the pharmacy transaction is just as complex; and it is anything 
but clear and simple, and this is because of the pharmacy benefit 
managers.
  They have used direct and indirect remuneration fees, DIR fees, to 
claw back money from pharmacies on individual claims, long after those 
claims are believed to have been resolved.
  It means that a pharmacy doesn't know how the final reimbursement 
amount will be received for a claim for weeks or even months. And 
anyone who runs any business, healthcare business or any other 
business, knows you can't operate when you don't know what your 
reimbursement is.
  CMS recently proposed drug pricing rules addressing this issue head-
on by requiring all pharmacy price concessions, a subset of DIR, to be 
included in the negotiated price, which is the price the pharmacy will 
be reimbursed at the point of sale for dispensing the drug.
  This directive would move negotiated drug prices much closer to the 
cost of the drug for the Part D sponsor, essentially eliminating 
retroactive pharmacy DIR fees.
  Patients win when pharmacy price concessions are included in the 
negotiated price.
  I want to commend the administration for making lowering drug prices 
a priority; and I want to challenge my colleagues in the Democratic 
Party to work with the administration and the Republicans in this House 
to push forward legislation that would continue to reduce the cost of 
healthcare, specifically pharmaceuticals, for the American citizen.
  I, along with many of my colleagues on both sides of this aisle, have 
advocated for these sorts of reforms that bring transparency and 
accountability to the system.
  Now who could be against transparency and accountability?
  These are bipartisan issues on which we share broad agreement. I call 
on the leadership of this House to put the partisan politics aside; 
follow the lead of the administration; or walk with the administration 
to address the lack of transparency in the pharmaceutical industry. 
Give pharmacies a level playing field to compete, and provide Americans 
access to affordable prescription drugs.

  This is something that we should have done for the American citizens 
long ago and it is something that we can do right now.
  Madam Speaker, I thank my good friend and fellow Georgian, Mr. 
Carter, for hosting this Special Order this evening. I look forward to 
continuing to resolve this issue for the American citizens.
  Mr. CARTER of Georgia. Madam Speaker, I thank the gentleman for his 
comments, and I thank him for his work. He truly has been a champion 
for his constituents.
  His father is a doctor and, certainly, he understands healthcare. As 
he mentioned, he was an insurance broker, he understands insurance. And 
a lot of what we talk about here is insurance.
  Let me try to articulate, if you will, exactly what I am talking 
about here. Some of the folks back home who are watching may be 
thinking, well, I don't really understand why the pharmaceutical 
manufacturers have to go through the PBMs.
  What happens is that insurance companies work on formularies. In 
other words, they say, if you have got this disease, or if you have got 
this health problem, these are the drugs that we are going to cover.
  The pharmaceutical manufacturer, in order to get their drug on that 
formulary, has to go to the PBM, the middleman, and has to offer them 
discounts, rebates, if you will, in order to get their product on that 
formulary.
  That is what we are talking about. That is where they have the 
pharmaceutical manufacturers by the short hairs, if you will. That is 
where they really put the pressure on. So that is really what we are 
talking about.
  Look, again, as I have said before, I am not opposed to anybody 
making money, but show me the value.
  I mentioned a hearing that we had earlier today in the Health 
Subcommittee of the Energy and Commerce Committee. I mentioned that we 
had some PBMs there. We had two PBMs there. One is one of the major 
PBMs that requires the pharmaceutical manufacturers to give them 
rebates in order to have their products listed on the formulary.
  And then another PBM was there, and they are just a flat fee. In 
other words, they just charge an administrative fee. That is all they 
charge. Again, PBMs, that is the way they evolved. All they were to 
begin with, when they started way back when, were just simply 
processors.
  But enough about what we have done here in Washington. Let's talk for 
just a minute about State legislators and what State legislative 
actions have been taken.
  Let me clarify and let me point out that I am not talking about just 
red States. I am not talking about just blue States. I am not talking 
about big States. I am not talking about small States. I am talking 
about all States, all the States in our union;
  I am talking about States like Ohio. Ohio's Department of Medicaid 
published a report in January detailing exactly how PBMs have been 
gaming the system; that's right; in Ohio.
  Ohio found that CVS--CVS is Caremark--that they had been using their 
role as the PBM for their State Medicaid program to pay CVS pharmacies 
as much as 46 percent more than competing pharmacies.
  Now, this is something else we need to talk about. We need to talk 
about

[[Page H3661]]

what is referred to as vertical integration. That is, right now, where 
the insurance company owns the PBM and owns the pharmacy.
  The top three that I mentioned earlier that control 80 percent of the 
market, that is the case with all of them. CVS is the pharmacy. 
Caremark is the PBM. Aetna is the insurance company.
  Now, when we were talking to the PBMs today in the committee, we 
would ask them, what are you doing with these discounts? What are you 
doing with these rebates that you get? And they would tell us, well, we 
give them back to the plan sponsors, and the plan sponsors decrease 
premiums.
  Anybody seen their premium decreasing recently? I don't think I have.
  But think about it for a moment. If the insurance company owns the 
PBM, and owns the pharmacy, if the PBM is going to give it back to the 
insurance company, isn't that just taking money out of one pocket and 
putting it in the other pocket?
  I mean, if CVS--if Caremark is going to give back the money that they 
are saving in the third party with the PBMs to the insurance company, 
Aetna, that they also own--and they are not the only one.
  What about Express Scripts? Express Scripts just recently bought 
Cigna. So you have got Cigna as the insurance company. You have got 
Express Scripts as the PBM. And, oh, by the way, Express Scripts has 
their own mail order pharmacy and in terms of volume, they are the 
third largest in America. So, again, we have the situation there.
  Same thing goes with United, UnitedHealthcare owns Optum, and they 
have their own mail order pharmacy.
  So, there you have the three top PBMs, controlling 80 percent of the 
market; that also have their own insurance company, and they also have 
their own pharmacy.
  This is what happened in Ohio. Ohio discovered that Caremark, that 
third party, the PBM, was paying their pharmacy, CVS, 46 percent more 
than they were paying competing pharmacies. That is an example of where 
they were taking money out of one pocket and putting it in another 
pocket.
  What about New York State? Their State Medicaid reported that PBMs 
were pocketing a 32 percent markup on generic drugs; 32 percent markup 
on generic drugs; the drugs patients traditionally rely on to be more 
affordable than their branded alternatives. But New York caught them 
red-handed.
  I can go on and name State after State. The State of Arkansas called 
a special session to address the situation with PBMs.

  Just yesterday, my home State of Georgia, the Governor signed into 
legislation two bills dealing with PBMs; one of them that would 
prohibit PBMs from steering their patients to their own pharmacies and 
steering them away from other pharmacies, independent pharmacies.
  So this is just not the Federal Government acting on these issues. We 
have had States who have acted on these issues as well.
  So let's talk about a couple of other things that we have done in 
Congress. One thing that I want to mention, because I thought it was 
such an egregious thing that the PBMs were doing in the past--we, 
thankfully, were able to address this--was called the gag clause.
  Thankfully, we had legislation that I was honored to sponsor here in 
the House that was passed in the House, passed in the Senate, signed 
into law by the President. It addressed the gag clause.
  What is a gag clause?
  You want to talk about the audacity of the PBMs? Let me tell you 
about the audacity of the PBMs.
  As I mentioned earlier, about the pharmaceutical manufacturers being 
under pressure to give the PBMs discounts, rebates, if you will, in 
order to get their drugs on the formularies; well, independent 
pharmacies are the same way. They are under pressure.
  What the PBMs did is they told--they had a clause in their contract 
with the pharmacy, and it said that if a drug is cheaper if you buy it 
out of pocket, if you pay for it out of pocket, if you buy it for cash 
than the copay, you cannot tell the patient that.

                              {time}  1930

  And if you do tell the patient that, then you run the risk of being 
kicked out of the network. Well, the reality is you can't afford to be 
kicked out of the network. If you lose thousands of bodies because that 
PBM controls that network, then you are out of business.
  So pharmacies had no other choice. Patients were paying more with 
their copay than what they would have paid for it if they would have 
simply paid out of pocket, just simply paid cash. We did away with 
that.
  Thank you, Mr. President, for signing that legislation.
  We addressed that in Congress. We said, no, that is not going to 
happen anymore. Now pharmacists can do what they were trained to do, 
and that is take care of their patients and tell them, Look, if you pay 
for this, you can buy it for $4 and you don't have to pay a $20 copay.
  You say, Well, how often did that happen?
  Well, let me give you just one example that happened in our 
committee, in the Energy and Commerce Committee. We actually had one of 
our Members who was the primary caregiver for her husband, who was very 
ill at the time. We had been talking about the gag clause, so she knew 
about it. She knew that pharmacists weren't allowed to offer that 
information.
  So she went into the pharmacy, and she was told that her husband's 
medication, no exaggeration, was going to be $600. She knew to ask the 
pharmacist. She said, What if I just pay for it out of pocket? What if 
I just pay you cash? How much will it be?
  $40. $40.
  Now, granted, this is an extreme example, but it is an example.
  Thank goodness we did away with that. I thank the Senate for passing 
this. I thank the House for passing it. I especially thank the 
President for signing this into law.
  Madam Speaker, this is a real problem.
  I want to conclude by saying that what we are trying to do here is to 
bring about transparency. Just show us what is happening. That is all 
we are asking for.
  I want to applaud the administration. I want to thank President 
Donald J. Trump for bringing this issue to light. This has been an 
issue that he has worked on.
  This is a nonpartisan issue. I never in my years of practicing 
pharmacy asked someone, Are you a Republican or a Democrat? That 
doesn't matter. This impacts everyone.
  I thank the President for his leadership on this and I thank the 
administration for these two proposed rules: doing away with DIR fees, 
making the rebates at the point of sale, so that they will truly go to 
the patient.
  These two rules that are being proposed by CMS will help get us to a 
point where we will have more transparency. That is what we need.
  Folks, this is a serious subject, a very serious subject. I have 
witnessed it firsthand, witnessed it in my practice of pharmacy for 
over 30 years. It is horrible when you see someone suffering who can't 
afford a medication.
  I call on the pharmaceutical manufacturers to do their part. They 
have got to do a better job with their pricing. They are not without 
responsibility here, and I think they understand that.
  But, Madam Speaker, we have got to have these two rule proposals 
passed, and I encourage CMS to follow through on this, do away with DIR 
fees, put the rebates at the point of sale. This will bring about 
transparency.
  I thank the administration for their support. I thank those who spoke 
here tonight.
  Madam Speaker, thank you for giving me this opportunity to bring to 
light this extremely important subject.
  Madam Speaker, I yield back.

                          ____________________