[Congressional Record Volume 165, Number 115 (Wednesday, July 10, 2019)]
[Senate]
[Pages S4753-S4759]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]



                        Prescription Drug Costs

  Ms. ERNST. Mr. President, I recently received a letter from a 
gentleman living in Cedar Falls, IA, who suffers from Parkinson's 
disease. As I speak, he is going without his $1,450-per-month LYRICA 
prescription in order to keep a roof over his head. That is right, 
folks. He must choose between making a mortgage payment and getting his 
prescription.
  Here is another story a woman from Davenport, IA, shared with me. 
Last October, she was able to get a 3-month supply of blood pressure 
medication for $17, but when she went to the pharmacy for her refill in 
late December, she was told the price had nearly tripled to $55. She 
wrote to me and said:

       Thinking this was a mistake, I refused the refill and 
     checked online about the change in price and found I couldn't 
     get it cheaper anywhere else. So I went back in ten days and 
     thought I would just have to pay the new cost [which was 
     $55]. In that time . . . the prescription had gone up to 
     $130!

  Whether I am talking to folks back home in my townhalls and other 
events on my 99 County Tour or in meetings right here in Washington, 
DC, the cost of prescription drugs is the No. 1 issue I hear about from 
Iowans. Every day, I hear stories just like these about the outrageous 
costs associated with their prescription medications.
  For too long, hard-working Iowans have borne the brunt of 
skyrocketing prescription drug prices. Stories like the man from Cedar 
Falls and the woman from Davenport have become the norm. We have to 
change that, and that is exactly what we are doing here in the Senate.
  We have been hard at work in advancing bills to drive down drug 
prices, increase competition, and close costly loopholes that are being 
exploited by those bad actors. I am proud to lead on three such bills 
that were recently approved in committee.
  First, I have teamed up with Senator Cotton on a bill that aims to 
eliminate an egregious loophole in the patenting process. This loophole 
allows drug companies to take advantage of the well-intentioned concept 
of sovereign immunity for Native American Tribes in order to dismiss 
patent challenges and unfairly stifle competition.
  Our legislation would put an end to this manipulative practice and 
actually provide Iowans with access to cheaper options for their 
prescription drugs. That is not all we are doing in the Senate to make 
more low-cost generic drugs available to folks in Iowa. We have also 
been working across the aisle on a bipartisan bill that would put a 
powerful check on drug companies seeking to keep generics off the 
market.
  The bill would empower the makers of generic drugs to file lawsuits 
against brand-name manufacturers if they fail to provide required 
resources, such as drug samples, needed for generics to clear the 
regulatory process. In turn, we would see cheaper alternatives 
available for my folks in Iowa.
  I am also working with my fellow Iowan, Senator Grassley, on a bill 
that focuses on the middlemen behind some of the prescription drug 
price hikes we have seen recently. The bill would direct the Federal 
Trade Commission to examine anti-competitive behavior in the 
prescription drug market. As mergers push drug prices higher and 
higher, this bill will be instrumental in helping Congress develop 
policies to increase competition and lower those costs for both 
patients and our taxpayers.
  Make no mistake. The rising cost of prescription drugs is an issue 
that significantly impacts hard-working Iowans. We in Congress have a 
responsibility to take action, to give folks a voice, and to make sure 
no family is ever forced to choose between making a mortgage payment 
and purchasing their medications.
  That is what we are doing. We have some great bills in the Senate--
bills from both Republicans and Democrats--that can help lower those 
drug prices, increase competition, and close loopholes. Let's build on 
this effort and continue working together in a bipartisan way to get 
these bills and others across the finish line and signed into law. 
Iowans are counting on us.
  I yield the floor.
  The PRESIDING OFFICER (Mr. Perdue). The Senator from Florida.
  Mr. SCOTT of Florida. Mr. President, as is now obvious to everyone, 
ObamaCare made healthcare even more expensive. Premiums are up. Copays 
are up. Deductibles are way up. ObamaCare has been a disaster, and even 
the Democrats are admitting it.
  Let's all remember, ObamaCare was sold and based on a bunch of lies. 
You didn't get to keep your doctor, your health plan, and your premiums 
didn't go down.
  The Democrats want Medicare for All, which will absolutely ruin the 
Medicare system and throw 150 million people off of the employer-
sponsored health insurance they like. That would be a disaster. There 
is something we can do and must do right now to help American families: 
We must lower prescription drug costs.
  This is very personal to me. I grew up in a family without 
healthcare. My mom struggled to find care for my brother who had a 
serious disease. Eventually she found a charity hospital 4 hours away 
for his treatment. I remember asking my mom how much lower drug costs 
would have to be for her to consider changing pharmacies. Without 
missing a beat, she said: a dollar.
  This story is not uncommon. All over my State I hear the same thing: 
Drug prices are rising, and we are having trouble affording the 
lifesaving medication we need.
  I recently met Sabine Rivera, a 12-year-old from Naples, FL, who was 
diagnosed with type 1 diabetes more than 2 years ago. She is 12 years 
old, and she is already worried about how she will

[[Page S4754]]

afford the rising cost of insulin--something no 12-year-old should ever 
have to stress about.
  Patients want to shop for better coverage and lower costs, but too 
often they can't or don't know how. At the same time, pharmaceutical 
companies are charging low prices for prescription drugs in Canada, 
Europe, and Japan but charging American consumers significantly more. 
Why? Because for too long politicians have done nothing.
  American consumers are subsidizing the cost of prescription drugs in 
Europe and Canada and all over the world. Why should we be doing that? 
That certainly is not putting America first, and that is not putting 
American families first. That is why I am working with President Trump 
and Republicans and Democrats in Congress to fix this problem.
  I recently introduced the America First Drug Pricing Plan with 
Senator Josh Hawley to take real steps to lower costs for patients and 
put the consumers back in charge of their healthcare decisions. Part 
one of my bill focuses on transparency.
  First, pharmacies must inform patients what it will cost to purchase 
drugs out of pocket instead of using their insurance and copays. If 
patients choose to pay out of pocket, which is sometimes cheaper, the 
total cost would be applied to their deductible.
  Second, insurance companies should, and must, inform patients of the 
total cost of their prescription drugs 60 days prior to open 
enrollment. This allows patients to be consumers and shop around for 
the best deal.
  Finally, my bill would simply require that drug companies cannot 
charge American consumers more for prescription drugs than the lowest 
price they charge consumers in other industrialized nations.
  I have found that provision to be controversial in Washington. Do you 
know where it is not controversial? Everywhere else. In Tampa and 
Orlando, Miami and Panama City, all over Florida, this just makes 
sense. I don't spend a lot of time outside of Florida, but I would 
wager and say that across the country my bill would make a lot of sense 
too.
  Why would we as American consumers, who make up 40 percent of the 
market for prescription drugs, pay two to six times more for drugs than 
consumers in Europe or Canada or Japan? That needs to change. My bill 
takes real steps to change this, and I believe it should have 
bipartisan support.
  I also led seven of my colleagues in a letter to pharmaceutical 
companies asking them to work with us on solutions to lower the cost of 
prescription drugs. We are still waiting to hear back.
  American consumers are facing a crisis of rising drug costs, and we 
can't wait any longer. I will not and cannot accept the status quo of 
rising drug costs. We need to get something done this year, and I am 
fighting every day to make sure we do.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from West Virginia.
  Mrs. CAPITO. Mr. President, I am pleased to join my colleague on the 
Senate floor to talk about an extremely important topic--that is, 
lowering the cost of prescription drugs in this country. Just a few 
weeks ago, on June 20, West Virginia celebrated our 156th birthday. 
There is plenty to celebrate about West Virginia, from its breathtaking 
beauty and wonderful families to our kind and hospitable West Virginia 
spirit.
  Unfortunately, West Virginia has its challenges, too, including 
health challenges. We have some of the highest rates in the Nation for 
heart disease, diabetes, cardiovascular disease, cancer, and arthritis. 
While there are many nonpharmaceutical steps people are taking to 
prevent and control diseases, for many, their prescription medicine is 
the difference between wellness and illness or even between life and 
death.
  That is why it is so important that West Virginians are able to 
secure their medications and that we as a Congress make sure they are 
not paying too much for those medications. Of all the issues that my 
constituents come to me with--whether it is a phone call, a letter, or 
casually running into them at the grocery store--this is the issue I 
hear most about because it is something that affects so many West 
Virginians' way of life, and it is something that affects them every 
day. If it doesn't affect them, it affects somebody in their family.
  The same can be said for Americans across this country, and that is 
why it has become one of our Nation's top priorities, one that is 
shared by Republicans and Democrats and one that is a significant 
bipartisan focus of this administration and this Congress. It is a far-
reaching problem with many different factors contributing to it, and 
that is why we have to address it on many different fronts.
  The chairman of the HELP Committee is here today. He has worked 
through his committee diligently, and I applaud him for his efforts and 
look forward to joining him on the floor in support of those efforts.
  As we all know, the path a medication takes from the manufacturer to 
the patient is very complex, with many factors impacting the price a 
consumer pays. While making changes to this pathway is very important, 
my constituents really don't care about the pathway. They are more 
concerned with the total on their bill that their pharmacist is ringing 
up. That is why I have focused a lot of my personal efforts on the 
important role that our pharmacists play in lowering drug costs.
  In many small towns and rural communities--which is my entire State--
pharmacists are the healthcare providers people go to quite regularly, 
and they are often some of the most trusted, friendly, and welcoming. 
It is essential that patients, especially seniors, are able to access 
the local pharmacy.
  West Virginians and Americans across the country should be able to 
trust that their pharmacist is not being restricted about telling them 
how to get the best prescription drug prices. They need to know they 
aren't facing higher cost sharing for drugs and being accelerated into 
the coverage gap or the doughnut hole phase of Medicare Part D due to 
an overly complicated system of fees and price concessions that nobody 
really understands--certainly not at the pharmacist's desk.
  In order to ensure that seniors have access to a pharmacy of their 
choice, Senator Brown and I introduced the Ensuring Seniors Access to 
Local Pharmacies Act last Congress. We will be reintroducing this bill, 
which requires that community pharmacists in medically underserved 
areas be allowed to participate in the Medicare Part D preferred 
pharmacy networks.
  Why is this important? If a local pharmacy is not included in a 
preferred network, a senior must either switch to a preferred network 
pharmacy, which could be a lot farther away or less convenient, or pay 
higher copayments and coinsurance to access their local pharmacy. In 
some cities and towns, you can find a pharmacy on nearly every corner. 
In rural areas, that is just not the case, and accessing a preferred 
pharmacy could require significant time and difficult travel.
  Additionally, many seniors rely on their local pharmacies not only to 
access prescription drugs but also to receive those needed services 
like preventive screenings and medication therapy management.
  As important as access to a local pharmacy is, it is also essential 
that patients can trust their pharmacists to let them know which 
payment method provides the most savings when purchasing their 
prescription drugs.
  I was proud to join Senator Collins last year as a cosponsor of the 
Patient Right to Know Drug Prices Act. This commonsense bill, which the 
President signed into law in October, bans the use of the pharmacy gag 
clause. It was hard to believe this still existed. These clauses were 
put into place by insurers and pharmacy benefit managers, and they 
prevented our pharmacists from proactively telling consumers that their 
prescriptions could cost less--less--if they paid out of pocket rather 
than relying on their insurance plan.
  I am also currently working with Senators Tester, Cassidy, and Brown 
on legislation that would help improve transparency and accuracy in 
Medicare Part D drug spending. Our bill would reform the application 
process of pharmacy price concessions, also known as direct and 
indirect remuneration, or DIR fees, in the Medicare Part D Program. It 
sounds complicated, but it is driving up the cost of our 
pharmaceuticals.

[[Page S4755]]

  This will ensure that our seniors are not facing higher cost sharing 
for their drugs or, again, being accelerated into the coverage gap. It 
will also help ensure that local pharmacies are able to stay open. This 
is critical. We have to keep our local pharmacies open for a vast 
majority of rural America and have them continue to stay open and 
continue to serve Medicare beneficiaries and other communities that 
rely on them. It would provide needed financial certainty for these 
pharmacies, which are often small businesses.
  My colleagues and I hope to see this legislation included in the 
soon-to-be-released Senate finance package. These are just a few 
examples of how we are working to lower prescription drug costs.
  I have been listening to my colleagues and have heard a lot of other 
ideas. They are small but much needed steps that can be, and already 
are, making a real difference in our constituents' lives, but our work 
is far from over. We have to continue looking at both commonsense and 
complex solutions to the problem. This is a complex problem. While as a 
Congress and a country we may not agree on the best way to do that, we 
do all agree that it is a problem that needs to be solved.
  I look forward to continuing to work with Senator Alexander and 
Senator Lankford, who are on the floor here today, and my other 
colleagues and the administration to find that pathway forward to 
lowering the cost of prescription drugs.
  I yield back.
  The PRESIDING OFFICER. The Senator from Tennessee.
  Mr. ALEXANDER. Mr. President, I thank the Senator from West Virginia 
for working to reduce the cost of prescription drugs. That is the 
question I hear most often in Tennessee: How can I reduce what I pay 
for out of my own pocket for healthcare costs? The most obvious way to 
reduce what you pay out of your own pocket for healthcare costs is to 
reduce the cost of prescription drugs.
  Shirley, from Franklin, TN, is one of those Americans who asked me 
that question. This is what she said:

       As a 71 year old senior with arthritis, I rely on Enbrel to 
     keep my symptoms in check. My copay has just been increased 
     from $95.00 to $170.00 every ninety days. At this rate I will 
     have to begin limiting my usage in order to balance the 
     monthly budget.

  There has never been a more exciting time in biomedical research, but 
that progress is meaningless if patients can't afford these new 
lifesaving drugs.
  Last month, as Senator Capito mentioned, our Senate Health Committee 
passed legislation by a vote of 20 to 3 that included 14 bipartisan 
provisions to increase prescription drug competition as a way of 
lowering generic drug costs and biosimilar drugs that reach patients.
  Here is what that includes: The CREATES Act--the Senator from Iowa, 
Mr. Grassley, is on the floor. He, Senator Leahy, and many others have 
proposed the CREATES Act, which will help bring more lower cost generic 
drugs to patients by eliminating anticompetitive practices by brand 
drugmakers. That is in the bill we approved. It also includes helping 
biosimilar companies speed drug development through a transparent, 
modernized, and searchable patent database. That was proposed by 
Senators Collins, Kaine, Braun, Hawley, Murkowski, Paul, Portman, 
Shaheen, and Stabenow. This legislation we have was approved 20 to 3. 
There are 55 different proposals by 65 different U.S. Senators--about 
the same number of Republicans and Democrats--all to reduce healthcare 
costs.
  Here are some other examples. The bill improves the Food and Drug 
Administration's drug patent database by keeping it more up to date to 
help generic drug companies speed product development, a proposal 
offered by Senator Cassidy and Senator Durbin.
  Another provision is it prevents the abuse of citizens' petitions. 
These are used to unnecessarily delay drug approvals. This was proposed 
by Senators Gardner, Shaheen, Cassidy, Bennet, Cramer, and Braun. 
President Trump included that in his 2020 budget.
  Another provision is it clarifies that the makers of brand biological 
products, such as insulin, are not gaming the system to delay new, 
lower cost biosimilars. That came from Senators Smith, Cassidy, and 
Cramer.
  Another provision is it eliminates exclusivity loopholes. These allow 
drug companies to get exclusivity and delay patient access to less 
costly generic drugs by just making small tweaks to an old drug. That 
came from Senators Roberts, Cassidy, and Smith, which President Trump 
also proposed in his budget.
  Another provision prevents the blocking of generic drugs. This is 
done by eliminating a loophole that allows a first generic to submit an 
application to FDA and block other generics from the market. Again, the 
President included this in his budget.
  Another provision in our bill prevents delays of biosimilar drugs by 
excluding biological products from compliance with U.S. Pharmacopeia 
standards. That sounds pretty complicated, but what it means is that it 
could delay patient access and lower the cost of drugs. Again, that is 
another proposal by President Trump.
  Another provision is it increases transparency on price and quality 
information by banning the kind of gag clauses Senator Capito talked 
about. These are gag clauses in contracts between providers and health 
plans that prevent patients, plan sponsors, or referring physicians 
from seeing price and quality information.
  Another provision bans pharmacy benefit managers from charging more 
for a drug than it paid for the same drug.
  Instead of remaining stuck in a perpetual partisan argument over 
ObamaCare and health insurance--and I can guarantee you that is going 
to continue to go on for a while--we have Senators on that side of the 
aisle and Senators on this side of the aisle working together to lower 
the cost of what Americans pay for healthcare out of their own pockets.
  Since January, Senator Murray and I have been working in parallel 
with Senator Grassley and Senator Wyden of the Finance Committee. They 
are continuing to work on their own bipartisan bill. Last month, the 
Senate Judiciary Committee also voted to lower the cost of prescription 
drugs. In the House, the Energy and Commerce, Ways and Means, and 
Judiciary Committees have all reported out bipartisan bills on the cost 
of prescription drugs.
  As I have mentioned, President Trump and Secretary Azar have been 
focused on this. Last year, the administration released a blueprint on 
steps the President would take to lower prescription drugs. Last year, 
the Food and Drug Administration set a new record for generic drug 
approvals. Generic drugs can be up to 85 percent less expensive than 
brand drugs.
  So I believe the cost of prescription drugs is an area where 
Democrats and Republicans in Congress and the administration can find 
common ground to help Americans reduce the cost of healthcare that they 
pay for out of their own pockets.
  I am very hopeful that our bill, with 55 proposals from 65 Senators, 
which has been reported to the Senate floor, will be placed by the 
majority and minority leaders on the Senate floor before the end of the 
month. We can pass it, the House will do their job, and we can send it 
to the President to lower prescription drug costs.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Oklahoma.
  Mr. LANKFORD. Mr. President, I rise to talk to this body again about 
healthcare and the cost of healthcare. This has been an issue and an 
ongoing dialogue for a long time around the Senate and around Congress.
  It is an issue that was supposedly settled when the Affordable Care 
Act was passed, but, ironically enough, my Democratic colleagues have 
now joined Republicans in saying they want to repeal and replace the 
Affordable Care Act. They are not using the term ``repeal and 
replace''; they are just saying they want to do Medicare for All. Built 
into that is completely taking out the Affordable Care Act and 
replacing it with something different.
  So, ironically, in some ways, we are in the same spot. We have both 
come to the same realization that the Affordable Care Act didn't pass--
it actually did pass, but it is not working. So now the challenge is 
what to do with healthcare.

[[Page S4756]]

  We are now trying to break into pieces what we can actually do 
together to get this done, beginning with the cost of prescription 
drugs.
  I continue to hear from Oklahomans all over the State about how hard 
it is to deal with the cost of prescription drugs, how rapidly the 
costs are increasing, and how sporadic the cost changes really are. 
They will have a drug that costs a small amount one month and come back 
a month later and find a dramatic increase for the exact same drug. 
They can go pharmacy to pharmacy and find a different price for the 
exact same drug or find that the pharmacy closest to them doesn't offer 
that drug, and a different pharmacy is the only one that is allowed to 
have that drug. The complexity is driving them crazy and rightfully so.
  As we peel back the layers on pharmacy issues, we are finding that 
the complexity is that cost overruns being built in are too high.
  For the past few months, we have looked at every step in the drug 
process, from the approval to research and development, to try to 
figure out how the cost is actually getting to the consumer.
  Along the way, several things have occurred. The administration has 
aggressively been approving generics. In fact, the administration has 
approved a record number of generics. Those generic pharmaceuticals are 
much less expensive than the branded pharmaceuticals. Many of those 
have been waiting a very long time at the Food and Drug Administration 
to actually be approved. The Food and Drug Administration is rapidly 
getting those out the door, and that helps consumers.
  Something else we have done in Congress is to try to address 
something called the gag clause. The gag clause is one of those things 
that was behind the scenes that no one knew about except for the 
pharmacists because, if you came in with your insurance card to pick up 
your prescription, the pharmacist knew the actual cost you would pay if 
you paid in cash. Often, you could get that same prescription for less 
by paying in cash than you could if you were to pay with your insurance 
card, but the pharmacist was prohibited from actually telling you that. 
We have addressed that in Congress, in a bipartisan way, to release 
that gag clause and allow pharmacists to actually tell people their 
options on pricing.
  You might say: That is an absolutely crazy thing. Who put that gag 
rule in?
  Well, the system, and the structure behind the scenes that negotiates 
all of it, said: If you want to be a pharmacy that sells these drugs, 
you have to submit to these rules. As we found, the culprit behind many 
of these issues is a group called pharmacy benefit managers. You will 
hear it referred to as just the PBMs.
  Those pharmacy benefit managers are supposed to negotiate between the 
manufacturers and the insurance plans to lower the prices. In many 
areas, they have lowered prices, but they have also given preferred 
formulary placement to some of their preferred pharmacies so some 
pharmacies get that drug and other pharmacies that are competing with 
them don't get access to that drug. Often, it is the drug that is the 
highest margin drug only their pharmacies will get and other pharmacies 
will not.
  It has become an anti-competitive piece in the background, when it 
was supposed to be something that was a highly competitive piece to 
actually help the consumer.
  Unfortunately, PBMs have created one of the most elaborate, complex, 
and opaque system of pricing, which has a tremendous amount of market 
distortion and at times has limited patients' access to those drugs. 
Oftentimes, it is a system they have been able to take advantage of and 
have created financial incentives to help their bottom line in the 
process rather than actually help the consumer.
  Many consumers have heard about rebates, but they wonder who is 
getting a rebate. They go to their pharmacy to pay for their drugs, and 
they are not getting the rebate. There is a rebate going somewhere, 
just not to them.
  Here is the challenge. We are trying to peel back with greater 
transparency what is happening in the pharmacy benefit manager world 
and figure out how a small group--it is actually three companies that 
have 90 percent of the market nationwide, how that middleman in the 
process actually handles pricing and negotiation.
  If you talk to any pharmacist anywhere in the country--and certainly 
across my great State--who is an independent pharmacist, they will all 
express their frustration with pharmacy benefit managers and their 
access to some drugs and not others and the stipulations they 
deliberately put there to hurt them and help others.
  I have joined my colleague Senator Cantwell in trying to shine some 
light on the operations of PBMs within the drug chains. Consumers 
deserve greater transparency. That will help us understand the actual 
cost of drugs and how those costs are actually getting to consumers or 
not to consumers in the process. The PBMs need greater examination, and 
we are finally taking that up to walk through the process.
  On the Finance Committee, we are dealing with several issues. Led by 
Senator Grassley, we are walking through Part B of Medicare, Part D of 
Medicare, and trying to examine what can be done to help the actual 
consumer. Our goals are how do we actually increase the options in 
drugs that are out there, how do we stop the cost increases, and how do 
we decrease out-of-pocket costs for pharmaceuticals.
  In Part B--these are drugs that are often intravenous, but they are 
done in a hospital setting or in an inpatient setting. As we are 
working through that process, we are trying to find the perverse 
incentives that are built in because, right now, physicians are 
actually paid a percentage of the medicine they prescribe in Part B. 
That means if there are three medications that are out there, if a 
doctor prescribes the highest cost medication, they get a much higher 
reimbursement. It is not a flat amount. Now, all three may be 
intravenous, but whichever is the most expensive actually helps the 
doctor the most. I am not challenging doctors and saying they are 
always prescribing the branded drugs and the most expensive in the 
process--that is between the doctor and the patient to determine--but 
there is no doubt a perverse incentive is built into this; that if they 
prescribe a more expensive drug, the doctor and his office actually 
benefit from it. We need to fix that.
  In Part D, there are reforms that can actually slow the growth in 
cost increases and allow people to have greater access to drugs. We are 
not interested in some kind of formula where we are actually going to 
decrease the patients' options of what drugs they can actually get in 
their formulary. That is a great thing about being an American; that we 
don't have limited formularies. It is very open in the process so 
Americans can try different pharmaceuticals to see which one works best 
for them. That is not chosen by government; it is chosen by them and 
their doctors. The Part D definitely needs a redesign of the benefit 
structure because right now things like the doughnut hole drive up 
costs for consumers. We are exploring a way to limit the out-of-pocket 
costs for beneficiaries so there is a lifetime cap sitting out there. 
There is an opportunity to know that if I end up with cancer or some 
other rare disease, I am not going to have these out-of-control costs 
on the pharmaceutical side and know there is not a doughnut hole 
waiting for me, where when I get a couple thousand dollars in, I am 
suddenly going to have a very expensive time. So I can afford my 
insurance in January, February, and March, but from April to August, I 
can't afford prescriptions anymore. We can't have that. We have to 
address those issues because that dramatically affects the out-of-
pocket costs.

  There are lots of other options we are looking at while working 
through this process, like the rebates, as I mentioned before, actually 
getting to the consumer, not to the companies behind the scenes, and 
dealing with how to take greater advantage of biosimilar drugs--very 
similar to the generic drugs but just in a different category and at a 
reduced cost--to allow them to have opportunities to get to those drugs 
faster. We have to deal with some of the patent issues to make sure 
drug manufacturers can't hold on to their patents abnormally long so 
the generics can't actually get out to people or bundle them together 
to restrict their patents.
  We have to end this practice of surprise medical bills. Some folks 
have no

[[Page S4757]]

idea what that is, and other folks know all too well. They look at 
their insurance. They go to a hospital that is in network, and their 
doctor is in network. So they go to a hospital that is in network, and 
they go to a doctor who is in network, but they get a giant bill from 
an out-of-network anesthesiologist, or the lab is out of network and 
the hospital is in network, and they get a giant bill from the lab. We 
are working to end the practice of having labs that are out of network 
or certain specialists a doctor has sent them to--the patient assumes 
they are in network, but then they find out that certain individuals 
who have taken care of them are out of network.
  We are also dealing with the issue of air ambulance surprise bills, 
which has been a great challenge for those folks in rural America who 
are having to be transferred long distances to get to a hospital and 
then are getting an enormous bill for an out-of-network air ambulance 
as a surprise billing. There are ways we can address this to deal with 
the out-of-pocket costs.
  We are focused on areas where we can find agreement and things we can 
do to work through this process.
  There is much to be done in the area of prescription drugs and in the 
area of in network, out of network, and surprise medical bills. We 
should be able to find common ground, and I am grateful I am part of 
this dialogue to help try to find ways we can come together, get this 
resolved, and get a better situation for American consumers and 
patients in the days ahead.
  With that, I yield the floor.
  The PRESIDING OFFICER. The Senator from Iowa.
  Mr. GRASSLEY. Mr. President, I want to update my colleagues and the 
American people about efforts to reduce the cost of prescription 
medicine.
  Last week, our country and the American people celebrated 
Independence Day, marking 243 years of self-government. As elected 
representatives, it is our job to make the government work for the 
people, not the other way around.
  For more than two centuries, our system of free enterprise has 
unleashed American innovation, investment, and ingenuity. Robust 
competition incubates advances in science and medicine. It leads to 
lifesaving cures and promising treatments for cancer, Alzheimer's, 
diabetes, and other debilitating diseases.
  However, prescription medicine too often smacks consumers with 
sticker shock at the pharmacy counter. The soaring prices leave 
taxpayers with a big tab--particularly under the Medicare and Medicaid 
Programs--and they weigh heavily on the minds of moms and dads all 
across the country.
  Last week, I held meetings with my constituents in 12 counties across 
Iowa. The cost of prescription drugs comes up at nearly every single Q-
and-A county meeting that I hold. Iowans want to know why prices keep 
climbing higher and higher. They want to know why the price of insulin 
keeps going up and up and up--nearly 100 years after the lifesaving 
discovery was made. They want to know what can be done to make 
prescription drugs more affordable.
  I am chairman of the Senate Finance Committee, and in that position, 
I have been working with Ranking Member Wyden from Oregon on a 
comprehensive plan to do just that. We have held a series of hearings 
to examine the drug price supply chain. We are working on a path 
forward. We are taking care to follow the Hippocratic Oath: ``First, do 
no harm.'' In other words, let's be sure we don't try to fix what is 
not broken. Americans don't want to give up high-quality lifesaving 
medicine. That is why I support market-driven reforms to boost 
competition and transparency, because with transparency brings 
accountability and the marketplace working more free of secrecy.
  Congress needs to get rid of perverse incentives and fix problems 
that undermine competition in the drug pricing system, including 
withholding samples by brand-name pharmaceutical companies, pay for 
delay, product-hopping, and rebate-bundling. There is too much secrecy 
in the pricing supply chain. Consumers can't make heads or tails of why 
they are charged what they pay for their medicine.
  President Trump has made reducing drug prices a top priority of this 
administration, and they have taken several steps under various laws--
including even under ObamaCare--to do things that give more freedom to 
consumers of medicine and on other healthcare priorities.
  In another instance, on Monday, the Federal court took a negative 
move, knocking down a rule that would require drug companies to 
disclose the price of their drugs in television ads. This is very, very 
disappointing. Senator Durbin and I worked on this in the last 
Congress, and I am going to continue to work with Senator Durbin to get 
this job done. Congress must correct what the Federal court said the 
administration didn't have the authority to do. I disagree with the 
court, but Congress can fix that. Big Pharma is already required to 
disclose side effects in their ads. Consumers ought to know what the 
advertised drug will cost. Today, I call upon my colleagues to climb 
aboard that effort Senator Durbin and I will be pursuing.
  Let's pass the bipartisan healthcare bills thoughtfully crafted in 
various committees. The previous three speakers spoke to some of those 
issues. Let's get these various bills correcting some of these problems 
over the finish line. Working together, we can drive down the price of 
prescription drugs without derailing quality and without derailing 
innovation, all of which saves lives and improves the quality of life 
for the American people.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Indiana.
  Mr. BRAUN. Mr. President, Senator Grassley and I attended the rollout 
of President Trump's Executive order to get the healthcare industry on 
the move. The chairman of the Finance Committee, the chairman of the 
Health, Education, Labor, and Pensions Committee, and Senators like 
me--I am a mainstream entrepreneur--came to the Senate to discuss 
issues just like this.
  I have probably been on the floor more than any other Senator, and 
every time I do it, I tell the industry: Wake up. I took you on 10, 11 
years ago, in my own business, to give good healthcare coverage to my 
employees. Year after year, it was a litany of, you are lucky your 
premiums are only going up 5 to 10 percent this year. You have all 
heard it before. It took risk, and it took some novel thinking, but it 
can be done. Most entrepreneurs aren't going to put the time I put into 
it to make it work for my own employees.
  When you hear Democrats, Republicans, three or four committees, and 
the President of the United States talking about a healthcare system 
that is broken, you should get it through your thick head that there 
need to be changes made. It shouldn't be coming from Congress, even 
though it will keep coming.
  I think the message is out loud and clear: Wake up and start fixing 
these things, or you are going to have a business partner whose name is 
Bernie Sanders and another idea of Medicare for All that we would 
regret once we got it. But, like most things here, like most big 
problems in this country, we wait too long to solve the issue.
  To give you a few things on what led me to be passionate about it, 
when I had to give up my own company's good health insurance, I had a 
very generic prescription that I needed to get renewed. There were 
eight pharmacies in the little town of Jasper, roughly, so I knew I 
would be able to get quotes. I had no health insurance. I was in 
between being a CEO of a company and a Senator. I said, I am going to 
try to see what this is going to be like. I knew it should cost 20 or 
25 bucks, maybe a little less.
  The first place I called, they stumbled around and couldn't even give 
me a quote on a common prescription. Finally, after about 3 to 4 
minutes, they said $34.50. I called another place that I thought would 
be a little quicker on its feet. It took 10 seconds, I got a quote for 
$10, and they said: By the way, you can pick it up in 10 minutes.
  That is more the way the rest of the economy works, but healthcare 
consumers have gotten used to not doing any of that heavy-lifting 
themselves. And believe me, the industry has evolved from Big Pharma, 
to big hospital chains, to the health insurance industry, which is in 
the middle of all of it. There are pharmacy benefit managers, and the 
drug companies give

[[Page S4758]]

them $150 billion worth of rebates, and through their costs and 
profits, less than half of that makes it to the consumer or to the 
pharmacy.
  The case is out there. We, as Senators and Congressmen on the other 
side, shouldn't need to be going to the floors of our Chambers to tell 
you the obvious: If you don't do these things, I don't believe we 
here--at the speed at which we normally operate--can do it quickly 
enough for you to save yourselves from that other business plan, which 
is Medicare for All.
  So what do we do to prevent that? No. 1, the industry should be out 
there doing what all other companies do--be transparent. In any other 
part of our economy, where do you not ask for and have plenty of 
information to work with. What does it cost, and what is the quality? I 
know that where I live, people would drive 60 miles to save 50 bucks on 
a big-screen TV that costs a thousand bucks.
  When I instituted a plan in my own business that encouraged my 
employees to do that, to have skin in the game, amazing things 
happened. Every time you pick up the phone or get on the web and look 
for that comparison, it is kind of hard to find, but it is there. The 
industry just needs to give more of it and not hide behind a system 
that has benefitted them. When we created that in my own business, 
people shopped around for prescriptions and routinely saved 30 to 70 
percent, as they do on MRIs, CAT scans, and most other procedures.
  I put the time and effort into it. Most CEOs--and you always hear 
about how employees are happy with their employer-provided insurance. 
That is because the employers are generally paying for anywhere from 85 
to 100 percent of it. So folks working somewhere don't really have skin 
in the game.
  Consumers of healthcare need to do what they do in all other 
industries and in all other things that they buy--take the time to ask 
how much it costs, what is the quality, and then the industry get with 
it so that we can fix the system before the other option actually takes 
place. There aren't enough CEOs and there aren't enough legislators to, 
I think, get the industry in shape, and the industry itself knows what 
these problems are. Get with it before you have a different business 
partner whom you won't like.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Louisiana.
  Mr. CASSIDY. Mr. President, I, too, come to speak today regarding 
pharmaceutical costs and what we can do to make lifesaving 
medications--and sometimes these medications make our lives a little 
bit better--more affordable to the average American.
  I happen to be a doctor, and I will approach these remarks as a 
fellow who has seen medicine evolve, who has seen the incredible, 
positive benefits of pharmaceutical innovation, but also as a doctor 
who sometimes saw that patients were unable to afford innovation. The 
question in my mind is, How do we give the patient the power to afford 
these innovative medicines, because if she cannot afford them, it is as 
if the innovation never occurred, and for her, it never did occur. So 
give the patient power.
  Let me make some remarks about pharmaceutical companies. There are 
some incredible examples.
  When I was in medical school, cutting away a part of one's stomach--
not the belly but part of the stomach; as I would tell patients, where 
the food goes after you swallow it--cutting away a part of the stomach 
because of ulcerative disease was one of the most common procedures 
done in surgery. Then histamine blockers came along, H2 blockers. 
Cimetidine was the first. All of a sudden, a surgery that was done 
multiple times a week was scarcely ever done. Those medicines are now 
sold over the counter.
  This morning, I got a little bit of arthritis, so I took my 
nonsteroidal anti-inflammatory, which used to be sold by prescription 
and now is over the counter, along with my H2 blocker, my Pepcid, which 
used to be sold by prescription but now is over the counter. I take 
them in the morning, and my back feels better. All of these are 
medicines that are generic, routine, and we almost--in fact, we indeed 
take the innovation for granted.
  I can go on. I am a liver doctor. Hepatitis C used to be an incurable 
disease which, in a certain percentage of those affected, would lead to 
cirrhosis, vomiting blood, liver cancer, and death. Now hepatitis C is 
cured by taking pills for several weeks. Amazing.
  Human immunodeficiency virus, AIDS. When I was in residency, if you 
got HIV, you died. There was no cure whatsoever. Now people live with 
it for decades. It is a disease you live with but do not die from. We 
speak of actually now developing cures for HIV.
  That is the promise of a vibrant pharmaceutical industry--people who 
not only live when otherwise they would have passed away but who also 
have a better quality of life.
  Now, that said, if the patient doesn't have the power, the patient 
has no leverage in this situation.
  I was recently with others in a conversation with the new head of the 
Congressional Budget Office. The CBO head said: You know, everybody has 
leverage in the healthcare marketplace except the patient. Everybody 
has leverage but not the patient.
  That is so true. Let me give some examples of how the patient lacks 
leverage in the pharmaceutical marketplace.
  First, I will say, if I go to church--and I do go to church 
regularly--and there is a Bernie Sanders supporter yanking on this 
lapel and a Donald Trump supporter yanking on this lapel and they are 
complaining about the same thing, they are talking about either 
surprise medical bills or the high cost of drugs. It is something that 
touches each American, but it doesn't have to be that way.
  Consumer Reports did an article over 1 year ago now in which they 
sent secret shoppers out to retail pharmacies to buy five generic 
medications, a prescription for each type--again, generic, like the 
over-the-counter pills I am taking. They went, and they paid anywhere 
from $66 to $900 for the same five drugs. Now, we can assume that the 
acquisition cost was about 60 bucks, because you could buy it 
someplace--an independent pharmacy or online--for $66, but three or 
four chain pharmacies were charging $900 for medications that they 
could acquire for less than $60.
  You could argue, why did the patient pay? Because we have so little 
advertising, if you will, cost competition, on what a generic medicine 
would cost. So imagine you have a health savings account, and you are 
going to buy your prescriptions, and you get charged $900 for something 
that should cost $60. This is the situation in which the patient has no 
leverage.
  By the way, you can ask, why didn't insurance cover it? It is because 
these patients were posing as uninsured. So the chain pharmacy figured 
out that it is the uninsured who do not have somebody working on their 
behalf who are going to be the most ripe for the picking for the high 
prices. The uninsured are the ones we are going to exploit, the ones 
paying cash. That is wrong. That is not the patient having the power; 
it is the patient being used as a victim.
  There are other things we can see. One is called evergreening. You 
have a drug, and you make just a little bit of a tweak to it that 
doesn't improve its importance or the efficacy of the drug--no clinical 
benefit--but it extends the intellectual property protections. Now laws 
that were conceived of and passed by Congress to reward innovation and 
to encourage creativity are instead being used to stifle competition 
and to extend patent lives so that we, the patients and the taxpayers, 
have to pay more--not for innovation but, rather because, somebody 
figured out how to evergreen it.
  So on the one hand, I am going to praise pharmaceutical companies for 
lifesaving drugs that have meant so much to me, my family, and everyone 
who is listening today, but I must also ask, why should we reward that 
which is not innovative but which is merely arbitraging laws meant to 
encourage innovation? We should not encourage arbitraging laws.
  There are other issues, such as patent abuse, where companies file 
large numbers of patents on parts of their drugs that are not 
innovative but are byproducts of the production process in order to 
keep out competition; citizen petitions, which typically come on 6 
months before a drug is about to become generic, so all of a sudden, we 
have all these petitions that must be navigated by the companies 
seeking to

[[Page S4759]]

introduce the generic; and the rebate system, which works to preserve 
market share but also to increase prices and to keep them high so 
patients do not benefit from competition.
  If we are going to say the patient should have the power in order to 
have lower prices, we can say right now that the system seems to be 
aligned against the patient.
  What can we do? Well, my office and others have several proposals in 
the current pieces of legislation going through, such as the so-called 
real-time benefit analysis. A prescription is ordered for a patient. 
The patient scans a barcode, and it would say: At this point, with your 
deductible and your copay, this is how much this drug is going to cost 
you, but there is a generic available, and you can get that generic 
instead. That would be a real-time benefit analysis that would save the 
patient money.
  We just talked to the folks at Blue Cross California. They are coming 
up with so-called gainsharing. If a patient selects a lower cost 
medication, the patient receives some of the savings that would 
otherwise have all gone back to the insurance company--another great 
idea. Senator Braun was speaking about the patient having skin in the 
game. In this case, there will be skin in the game because the patient 
shares the benefit with the payor for being cost-conscious. That is the 
patient having the power.
  We can also add value-based arrangements, which pharmaceutical 
companies, to their credit, have proposed. If you are the 
pharmaceutical company, you get paid only if the medicine works. If the 
medicine doesn't work, you don't get paid. If it does work, you do. 
That is a value-based arrangement. We have a bill with Senator Warner 
that would do that.
  I would also mention attempting to cap Part D exposure. If there is a 
senior citizen who is in the catastrophic portion of her policy, then 
you can cap the amount the senior might be exposed to. Under current 
law, she might be paying 5 percent of $100,000 worth of medicine. She 
is taking an essential drug to treat cancer, and she is paying 5 
percent of that $100,000, in addition to 5 percent of the other 
medications she is receiving. This is something many seniors cannot 
afford and this is something we as Congress can find mechanisms by 
which we can cap that exposure but still hold taxpayers whole.
  We have to enhance existing markets. As you might guess, my theme is 
that we should enhance it in terms of giving the patient the power, but 
we also have to preserve the innovation that has led to the great drugs 
I spoke about earlier. If all we do is steal intellectual property from 
the pharmaceutical companies, we will lose these innovative drugs. But, 
again, we need to have the drugs affordable for the patients. This is 
the tension--promote innovation but ensure affordability.
  We have a number of solutions, such as those I have just mentioned, 
in the HELP Committee and now in the Finance Committee. Republicans 
have solutions. My office continues to work on those. I look forward to 
working with my colleagues on their implementation.
  Mr. President, I yield the floor.

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