National Insulin Pricing Hearings Become Binge-Worthy (!)

Thinking about Congressional hearings on the current Insulin Pricing Crisis, your first instinct may be to roll your eyes and clench your fists. But hold on a moment... What we're seeing on Capitol Hill now may be something new, Folks.

We've reached a point where these Congressional hearings go beyond typical policy jargon to include intrigue and human drama that evokes hints of The Godfather, Robin Hood, and binge-worthy hits like Game of Thrones. After all, we're talking about people literally dying out there after rationing insulin because of unaffordability and lack of access.

OK, the GoT comparison may seem a bit extreme, but it actually came up in last week's two days of hearing on April 9-10. I was absolutely glued to the screen, in popcorn status, on the edge of my seat in suspense -- as I followed the 2.5-hour hearing before a House investigational subcommittee on Wednesday. Before this panel were six people: three representing the Big Three Insulin Manufacturers (Eli Lilly, Novo Nordisk and Sanofi), and three from the country's largest Pharmacy Benefit Manager (PBM) organizations (Cigna/Express Scripts, CVS/Caremark, and OptumRx).

The heated discussion brought some of us in Diabetes Online Community to tears, with people sharing emotes online in real-time to express cheers, laughs and hand-wringing as we listened to House members grill the players involved in supporting outrageously high insulin prices.

We've now had four Congressional hearings in 2019 addressing insulin pricing and diabetes issues, and the Oversight and Investigations Subcommittee of the House Energy and Commerce Committee on April 10 was the first to bring all three insulin manufacturers together, along with PBMs, to the same panel. There was a Senate Finance Committee meeting the day prior, and a week earlier the House E&C's investigational subcommittee heard testimony by D-advocates from the ADA (American Diabetes Association), JDRF, DPAC (Diabetes Patient Advocacy Coalition), the Endocrine Society, and longtime T1D Gail deVore from Colorado who's individually advocated on these personal #insulin4all efforts. The first hearing this year took place in January, which followed a handful of other prior hearings in recent years.

In this latest session, Congressional members hammered these execs with probing questions. To put it mildly, it was pleasing to watch, even if we ended up hearing the same repeated non-answers and finger-pointing from each side of the insulin supply chain. Honestly, I'm a policy wonk so I've followed a lot of formal hearings in my day... but this felt different to me.

Here's my personal recap of these unusually suspenseful hearings, including some of the best quips from Congress members: 

Game of Thrones, Diabetes Style

A huge theme of many recent Congressional hearings on this topic has been that lawmakers were visibly irate, furious with the drug pricing players testifying before them. Last week it was clear that they came ready for a fight, and the oft-contentious hearing gave those of us in the Diabetes Community a clear sign that these elected leaders have been listening to us.

Seriously, just when you thought you'd heard something that would top the drama, another member of the Congressional panel went for the one-up. It was delightfully satisfying, yet maddening.

Sen. Ron Wyden (D-OR), who co-chaired the Senate Finance Committee hearing, described the PBMs as being too secretive, accusing them of guarding their negotiations with Pharma and rebate schemes "with greater secrecy than HBO is guarding the ending of Game of Thrones."

"If PBMs had clear, hard evidence proving that they're getting patients a better deal on prescription drugs, they'd be leafleting the countryside and shouting from the rooftops," Wyden said. "Instead, they work overtime to keep patients and taxpayers in the dark."

The Pharma and PBMs execs of course countered that the convoluted existing healthcare ecosystem ties their hands on adjusting pricing. Even if there are nuggets of truth to that, Congress wasn't having it. Just like us frustrated patients, the Congress-folk seemed tired of it all and angry as hell. They frequently interrupted, not interested in the same song-and-dance about how broken the system is and finger-pointing on who's to blame. Even one of the execs suggested that they should "work together with Congress to find solutions," the Congress-folk weren't taking it. The effect was eye-rolling and laughable.

Rep Janet Schakowsky (D-IL) was one of the most forceful, bringing Godfather-like threats into her strong wording against the Pharma and the PBM reps on the panel -- which seems fitting, given the term "insulin pricing cartel" that's been floating around to describe this whole issue.

"How do you people sleep at night?" she asked rhetorically, before going off on a rant about how unacceptable the situation is. "That will not stand in this Congress. If you think you can out-talk us, without any transparency, your days are numbered."


Meme-Worthy Moments from Fed Up Lawmakers

Unfortunately, the bottom line is that beyond this rough grilling from lawmakers, we didn't hear anything new. The Pharma folk repeated their usual talking points on how PBM business models and rebate schemes are to blame for higher list prices (even though net prices and insulin profit is steady); while PBMs claim it's Pharma that sets high list prices for no apparent reason other than greed, and that the PBM companies pass along all rebates to their business, government and health plan clients altruistically.

Uh, huh...

You can get a run-down of what the company execs actually said in their pre-submitted remarks leading up to both the House and Senate hearings.

But there were many memorable moments and firsts that hint at a growing no-tolerance policy from lawmakers across the aisle, aimed at both the PBMs and Pharma industries.

Meme-Worthy Finger-pointing: A fave moment came when Rep. Joseph P. Kennedy III (D-MA), crossed his arms and shook his head multiple times before finally highlighting the execs' finger-pointing by jabbing out his own fingers this way and that in a meme-worthy way.

Meme of Disgust: Rep. Frank Pallone (D-NJ) had another meme-worthy moment when he was drilling into the statements and business practices of both Pharma and PBMs. He was clearly frustrated to the point where he looked like he might just toss up his papers in disgust. Then at one point while wondering why Congress doesn't just do away with PBMs or force price-controls, he just shook his head and put his hand on his face.

"Reverse Robin Hood": This was actually a phrase used by Sen. Bill Cassidy (R-LA) during the Senate Finance Committee hearing, when describing how the PBMs (and by extension, Pharma that wasn't present on that panel) gamed the system to take from the poor and give to the well-off.

"Political Jujitsu": Sen. Sheldon Whitehouse (D-RI) had a great line about PBMs using "political jujitsu of almost magical variety" to transform the public pressure on Pharma's pricing policies into better messaging for its own business practices, casting these middle-men as innocent antagonists and Pharma as the main villains.

Office Space: In a sense, all of this talk made me think of the movie Office Space that's marking its 20-year anniversary this year. There's a scene in which bosses, aka the "The Bobs," are interviewing employees about their respective roles in the company, as part of a process leading to company layoffs. As one character is awkwardly describing his tasks, they interrupt and ask: "What exactly do you do here?" In a way, that's how these Congressional hearings felt, like lawmakers were trying to get at some very basic information but kept getting only disjointed talking points in response.

"A Cruel Form of Torture": Sen. Paul Tonko (D-NY) asked the execs point-blank if they had ever struggled to afford insulin themselves or known anyone personally who had to ration or may have died as a result. They all responded no, and echoed "No one should." This set Tonko off, to the point of saying they've all collectively played a part in "a cruel form of torture" in their pricing policies and use of esoteric terms like "rebates, list prices, and Patient Assistance Programs" that ignore the reality of this real crisis in America.

Just Stop: I loved it when Rep. David McKinley (R-WV) asked posed a question to the Novo Nordisk exec, who then began what sounded like a commercial spot for Tresiba insulin, and the Congressman cut him off with, "I don't need to be filibustered here." NICE!

Smoke and Mirrors, etc.: Many other quote-worthy phrases popped up as well that capture what most us think about the insulin pricing system: "smoke and mirrors," a "bizarre and perverse" system, and one Congress member noting that the entire process is a "market failure at best" which encourages anti-competitive behavior.

There were so many more, but you'll just have to watch the hearings yourself to gauge the many high drama moments worthy of movies or cable TV series.

A Bipartisan Push for Fair Drug Pricing?

As noted, it was an incredible feeling watching lawmakers shake down these executives with so little tolerance for the typical blame game. Not only that, but these politicians seem to be cooperating with each other against the common enemy here.

Rep. Buddy Carter (R-GA), who wasn't even on the House E&C's subcommittee but came to make a statement, offered a point that seemed to sum the hearings up perfectly: “I want to congratulate all of you today for accomplishing something we’ve been trying to do in Congress, and that is to create bipartisanship." On the pricing madness itself he noted, "I have witnessed it. I have seen what you’ve done. This is going to end.”

Of course, how and when insulin prices actually come down significantly and stabilize is still TBD, because there are so many moving parts to this crisis in America. But one thing seems clear: Congress is hearing our collective voices and just like those of us in the D-Community, they're mad as hell and not going to take it anymore. That in itself is progress.

It makes for great viewing and a lot of hope. Now, onward towards tangible change please...


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