Copycat versions of expensive drugs may look the same, but the impact on consumer pocketbooks is far from identical

By Sally Greenberg, Chief Executive Officer, National Consumers League

To a scientist, a biosimilar medicine is designed to work like a brand-name medicine, with the molecular structure operating in a highly similar way in both therapies. The biosimilar medicine looks the same to a doctor, too, who can expect similar clinical results.

For many patients, though, the cost of the two medicines hit the pocketbook in hugely different ways. Today, many insurance plans ask patients to pay a percentage of the list price of certain medicines out of pocket – a practice called “coinsurance” – rather than a flat copay.

Even if that coinsurance percentage is the same no matter the drug, patients can pay vastly different amounts if one drug has a higher list price than another.

This has become a quiet crisis for patients using the anti-inflammatory medicine Humira, the best-selling medicine in history. Humira carries a list price of about $7,000 a month, though insurance companies, through savvy negotiation, pay far less.

For patients with coinsurance – the specifics vary by insurer, but it’s usually around 25% of a medicine’s list price, with some plans setting a maximum per-prescription price – that could add up to more than $1,500 a month out of their own pockets to get a medicine they cannot do without. That’s a huge burden, but not a huge surprise to those who have witnessed their health insurance benefits become less and less generous.

Fortunately, there are new options. Biosimilar versions of Humira are now available that have a list price of close to $1,000 a month. For patients with a 25% coinsurance, the medicine costs $250 out of pocket.

That should be a no-brainer for consumers. Who wants to pay six times more?

Unfortunately, due to our ultra-complicated health care system, almost no one uses the cheaper biosimilar. In part, that’s because insurance companies like more expensive medicines because they can make more money from these drugs, and there are few policies in place designed to protect patients from this kind of behavior.

Doctors, too, may miss opportunities to offer patients lower-cost options. After all, when the brand-name product and biosimilar are both technically “covered” by a patient’s insurance, it seems like it shouldn’t matter which product is selected.

The truth is that because insurance benefits are all over the place, it does make a difference for some patients. A huge difference. Thousands of dollars’ worth of difference.

The good news is that there are efforts that can make this easier for consumers and their physicians. Industry, government, and advocates can commit to boosting education so that more Americans can understand their health plan.

Such an educational effort could also include a focus on coinsurance to ensure that no consumer ever gets surprised when they have to pay a percentage of an inflated cost.

But educational efforts only go so far. We cannot rely on solutions based around asking doctors and consumers to assume primary responsibility for navigating a broken system. Fixing this problem for good requires policymakers to act.

First, Congress needs to address the role the pharmacy benefit managers – the middlemen known as “PBMs” that determine how drug benefits are designed – have played in creating the distorted market structure that has led to health plan strategies designed to push costs onto consumers.

Bipartisan legislation has been introduced that would begin to correct this convoluted market and put an end to patients needlessly overpaying to pad the profits of PBMs, but congressional leaders need to prioritize reform. There may be few areas of consensus on Capitol Hill, but this is one of them, and it’s time to turn good ideas into law.

Second, meaningful market incentives need to be established to drive biosimilar uptake. This happened in the generics market decades ago, where clear incentives have driven generic drug penetration to the point where 91% of all prescriptions are for generic drugs.  Unlike biosimilars, patients who take generics see clear cost savings, which is a great motivator.

But no such incentives exist in the U.S. biosimilar market, offering an opportunity for Congress to create similar incentives where both patients and physicians share in the savings available from these lower-cost biosimilars.  Only then will consumers, and the U.S. health care system more broadly, realize the enormous potential of a sustainable biosimilars market.

Our health care system is complicated on purpose. Complexity makes it hard for consumers to see good deals, even when they’re right in front of them. That’s the scenario playing out with biosimilar versions of Humira: even if the drugs may be the same, the impact on patients may not be.

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About the National Consumers League (NCL)

The National Consumers League, founded in 1899, is America’s pioneer consumer organization.  Our mission is to protect and promote social and economic justice for consumers and workers in the United States and abroad.  For more information, visit nclnet.org.

PBMs claim new programs will save consumers money. Let’s take a closer look.

By Robin Strongin, Senior Director of Health Policy

Consumers have known for quite some time now that the prescription drug pricing system is essentially a black box. Dealings among drug manufacturers, health insurers and pharmacy benefit managers (PBMs) establish which drugs insurance will cover and make accessible to consumers. What’s more, the prices that consumers pay for those medicines vary wildly – often leading to high out-of-pocket costs for us all.

Two of the three major PBM companies that are in the middle of this drug pricing web recently announced that they are establishing new programs (CVS’s CostVantage and Express Scripts’ ClearNetwork) that set transparent formulas for drugs with a pre-set markup and a flat fee for the PBMs. On paper, this sounds like a great idea.

But consumers would be wise to take these claims with a healthy grain of proverbial salt. We know PBMs continue to find new ways to put themselves over patients (more on that here) and we must demand answers to the issues the PBMs are still skirting. For example:

  • Will these new programs actually make prescription drugs more affordable and reduce out-of-pocket costs at the pharmacy counter? Notably, both Express Scripts and CVS Health have acknowledged that employers and plan sponsors may not save any money from this move. There is no sign either that consumers will be able to get the drugs they need for a fair price.
  • While the companies boast increased transparency, they still have not shared – nor said they will share – how much they are paying to acquire the drugs that will be dispensed to patients. PBM clients have long sought this information, but it appears that data will still be hidden in the black box.
  • In the case of CVS Health, the changes the company announced will only be effective at CVS-owned pharmacies. It will not affect how CVS will reimburse millions of prescriptions at the local and independent pharmacies it doesn’t own. A cynic might say this is just another mechanism by CVS to drive more patients to its own pharmacies.

Most notably, nothing CVS Health and Express Scripts have announced will change one of the pervasive anti-consumer elements of the drug pricing system. In their dealings with drugmakers, they can still cut deals that will determine which medicines get preferential placement. This means PBMs could continue to push consumers toward higher-priced drugs and limit access to more affordable generics and biosimilars.

It’s no coincidence that Congress is getting closer to passing PBM reform legislation that would mandate transparency, force the PBMs to pass their negotiated savings from drugmakers to consumers and remove the incentives for PBMs to push consumers to higher-priced drugs. One might say that these moves by CVS and Express Scripts are cosmetic attempts to ward off legislation by touting their own self-reforms.

But, as with so much that goes on in the drug pricing game, these “reforms” may not be what they seem. We need Congress to step in for consumers to help ensure we’re no longer facing a big disadvantage at the pharmacy counter.

Learn more about the PBM problem at nclnet.org/pbms.

Congressional briefing: The path forward for a safe cannabis marketplace

By Robin Strongin, Senior Director of Health Policy

Cannabis Consumer Watch recently hosted a briefing on Capitol Hill to educate policymakers and staff on the public health risks that exist in the current cannabis marketplace, and to offer policy solutions that would help protect consumer safety and encourage innovation for patients. The briefing was moderated by the Collaborative for Cannabinoid Science and Safety’s Libby Baney, and the panel of experts included:

Robin Stronger, Senior Director of Health Policy, National Consumers League, who explained NCL’s biggest concerns about the current cannabis marketplace. She pointed out, “Out of over 140 CD products studied by the FDA, more than half were mislabeled and nearly 40 of those products had more than 120% of the CBD level listed. Several had pesticides and even toxic mold – we just don’t know what consumers are buying. And consumers aren’t aware of the risks.”

Dale Sutherland, President & Founder, CODE 3, who shared that during his time with DC Metropolitan Police Department, they saw, “how bad distribution efforts can be – product manufacturing and transportation conditions that aren’t heavily regulated present several unique health risks.”

Sue Thau, Public Policy Consultant, CADCA highlighted the negative effects cannabis products have on children in particular, explaining, “Poison control calls related to cannabis digestion are increasing each year – and that’s just the data that we do have – there isn’t an efficient way to track all the issues parents and families face.” She provided examples of THC products that use packaging similar to popular children’s snacks or are in packaging that appeals to kids.

From consumer health to law enforcement, to concerns around youth consumption, the unique backgrounds of the panel made for a robust conversation that included multiple perspectives on the cannabis issue. To learn more about the concerns highlighted during the discussion, visit our Cannabis 101 page here.

 

The return of Striketober and why consumers should care

By Eden Iscil, Public Policy Manager

The National Consumers League has a long history of fighting for both consumers and workers alike. Founded 124 years ago, NCL’s first major policy accomplishments included the establishment of minimum wage laws and protections around child labor. In support of these goals, much of the League’s early years were centered around consumer boycotts of companies that treated their employees unfairly.

Today, NCL’s support of workers’ rights remains just as critical as we find ourselves in another October with truly historic labor action. Two years after “Striketober,” 75,000 healthcare workers at Kaiser Permanente walked off the job in the largest healthcare strike in history largely due to low pay and understaffing. At the same time, 160,000 actors belonging to SAG-AFTRA and 25,000 members of the United Auto Workers continue to strike. The Writers Guild of America recently secured significant gains after a months-long writers’ stoppage, and UPS agreed to better contracts for drivers after 340,000 Teamsters threatened to withhold their labor.

Beyond the benefits for all workers that the presence of strong unions provides, it’s also in consumers’ self-interest to support workers agitating for better employment terms. As consumers, we rely on these employees to safely fly passengers across the country, provide critical healthcare services, and raise the alarm over unsafe food production. In addition to the harm that results from jeopardizing workers’ safety, poor working conditions can lead to indefinite closures, potentially reducing the amount of product on the shelves. In all of these cases, unions help consumers by advocating for adequate staffing levels to prevent worker burnout, securing healthy workplace environments, and ensuring robust whistle-blower protections.

Even for less perilous industries (i.e. not flying a plane or driving a truck), consumers should support workers fighting for better employment conditions if only to safeguard the continuation of their favorite products. The arts—including television, movies, and music—provide invaluable comfort and entertainment, in addition to awakening us to new perspectives, ideas, and values. Despite consumers’ intense love for these forms of entertainment, writers, actors, and musicians continue to struggle in their fields for fair compensation, something that can threaten (or at the very least, doesn’t promote) the future creation of high-quality art.

Industry has always threatened to raise prices if they are forced to pay their employees more. Consumers should understand that this is a choice corporate executives can make—but it is not the only possible outcome. Rather than price gouging consumers, companies can reduce executive compensation to offset the costs of fair wages. General Motors, one of the targets of the UAW strike, pays its CEO 362 times what it pays its median worker. Starbucks, a company infamous for its illegal union-busting, paid its former CEO nearly 1,400 times what it paid its median employee in 2022.

For this year’s resurgence of Striketober, consumers should do their part in supporting workers. Try purchasing union-made goods, shopping at worker-owned cooperatives (a directory of local co-ops can be found here while a list of large chains is viewable here), and supporting non-profit news organizations.

This summer, I dipped my toe into electric vehicle land: It was hit or miss

Sally Greenberg

By Sally Greenberg, Chief Executive Officer

This summer I bought a new used 2021 Prius Prime. I wanted to dip my toe into the world of electric vehicles and the Prime provided that opportunity. I call my purchase a “new used” because compared to my 2007 Prius, my Prime feels spanking new. I wanted a Prime because unlike a traditional Prius, it provides an electric charge for up to 25 miles; after the electric is used up, the car reverts to using fuel, albeit a very fuel efficient 62 mpg. My friend Sarah owns one and has been crowing since she bought it about filling up her tank a mere 4 times a year because that 25-mph charge takes her all over town and home in time to recharge. So, she uses no gas. That’s what I wanted!

But I do more than drive around town. I bought the Prime anticipating a road trip at summer’s end to the Maritimes in Canada where I would work remotely and be a tourist on weekends. I wanted my new car to get maximum fuel efficiency for the 4,000-mile trip so I pledged to charge the Prius whenever I could. I wasn’t quite sure how it would work, so part of my plan was to test out how average consumers with electric vehicles were faring.  I was committed to trying, even if it only gave me 25 miles on the electric charge.

What I discovered is that finding reliable electric charging stations is hit or miss. The Prime provides one advantage: it comes equipped with a charging cable that can be plugged into any 120-volt outlet. Granted, the 120-v plug in option takes over 5 hours for a full charge, but it’s better than no charge at all.

The problem is that when you’re on a car trip and staying in roadside hotels, finding a place to plug in a car even at a standard outlet isn’t easy. When you can find one, it takes longer but has the advantage of being free.

So, my adventure began. I picked up my Prius Prime on August 18 from a dealer outside of Philadelphia and headed north, first stop Norwalk CT. I had a hotel booked, but alas, when I arrived, I couldn’t find a charger at the hotel. I tried using the Apps but which ones to use? Flo? Charge Point? Are they the same company? It was hard to tell and plus, they tell you there’s a station, but the chargers might not be working at that station. So, I figured I would rely on the chain hotels I stayed at along the route and tried to stay in places which claimed to have chargers.

On to the next stop, Keene, NH. My Holiday Inn Express had no charging stations, so I went across the street to Hampton Inn, where I had to pay for the charge, $2.00 for a two-hour session, and I wasn’t told ahead of time what the cost was. Next stop was Rockland, ME. I googled and found a charging station but only at the public library. Again, if I’m like most consumers, I want to know what I’m being asked to pay before I decide to pay it. Again, no such luck here; you flash your credit card on the display at the charging station and hope it won’t break the bank; you get a green light and plug in your car. Thankfully, again it cost me only $1.50 to $2 for the full charge.  But I had to leave the car for 2 hours and go back to my hotel to kill time. It’s safe enough because you lock up and the charging port doesn’t provide any opportunity for theft or vandalism. Advanced planning would have allowed me to see the wonderful Farnsworth Museum in Rockland while my car was charging.  Another lesson learned!

The next overnight was Bangor, ME. The hotel staff pointed to the gas station next door; a guy sitting in a Kia was charging his SUV and I thought, great! Alas, neither of the charging ports fit my Prime. That was a surprise.  I went away dejected and googled for another possibility. I drove ten minutes to the public library downtown, which I read had received many thousands in infrastructure funding to put up charging stations. The display where you put your card was unresponsive. I couldn’t pay and couldn’t get the ports working. I called the phone number on the charging station and clueless operator picked up and thanked me for the report but said she couldn’t help me. I called Bangor city hall, and no one answered, so I left a message and my phone number – it was a Monday morning. No one ever called back. So I got no charge in Bangor.

Next, on to St. John, Canada. We were hoping the Canadians had figured it all out and the hotel would have the promised charging stations – they were there but neither was working. So, no charging in St. John.

Our next stop was Charlottetown, Prince Edward Island. The town is charming, and we were excited that the hotel advertised multiple charging stations; there were two and once again, neither was working. We got a maintenance guy to reset the charger and plugged in. Yes! A two-hour charge and for free!

The next evening though, we couldn’t get access to the charger because a van parked at the only working charging station from 6 pm till late the next morning and we had to hit the road. A woman in a Tesla next to me looked perturbed – she and her young daughter had rented a Tesla and had no access to a charger either. She reassured me she had another 30 kilometers of charge. But what if she didn’t have any charge to spare?  She’d have been SOL, as the saying goes.

Onto Sydney, Cape Breton, where the hotel had no charging stations, but they let us use a 120-v outlet in the parking lot and we happily charged up overnight for free.

Making our way around Nova Scotia, we landed in the lovely capital Halifax and our hotel advertised a free charging station. It worked for a change, but it wasn’t free. In fact, I made the mistake of plugging my car in overnight and waking up to a $12 charge on my credit card, even though the charge likely only took 2 hours. Again, I was never told about cost before plugging in. Another lesson learned! Don’t leave the car plugged in overnight when you don’t know the cost.

On the return to the US, we stopped again in St John for the night, at a different hotel which advertised charging stations. The stations were there, but both were out of order. A phone call to the customer service yielded no results. They took the report but couldn’t fix the problem. Again, no charge.

As the trip continued, I feel like I got smarter. Ask at the hotel for charging stations either on the property or in town. I learned to plan my day around charging – either the night before or in the morning, when I had things to do before hitting the road. If the hotel had a working station, great, I could get a fast charge. If not, find an outlet and go for the 5-hour charge. Move the car as soon as it is charged up. Working my way back to Washington DC, I used my newfound knowledge to find charging stations where I could. Several nights I just couldn’t find a way to charge.  Finally, I reached home and the relief of instant charging.

Two weeks later, I drove to see my son Durham, NC. Oh good, I thought, a town known for being part of the “Research Triangle” will be filled with techie EV owners and early adapters. I was wrong. The charging station in one trendy part of Durham was available but the chargers didn’t work for the Prime. We drove to a nearby garage where the guys said, “Sure, no problem, use our EV charger. Not sure it is working though.”  And it wasn’t. The hose was badly frayed and needed replacing. We drove all over town looking for a plain old 120 outlet outside. No luck, so no charge in Durham. So, my endless search for chargers on the east coast comes to a close.

Friends are enjoying my saga. Sally, they say, you’re only get 25 electric miles a day! I don’t care. I’m dedicated to reducing my carbon footprint and plus, it’s fun to drive around knowing you’re using no gas. That said, I would love to have a full EV, but I like to take road trips and I can’t trust the EV infrastructure and risk a car running out of juice. In fact, I don’t know exactly what happens if you do run out of charge.

I know that Tesla owners have better access and reliable charging stations, and for good reason.  According to JD Power, Tesla is the longest-running pure electric brand with about 114,000 vehicles delivered in the first quarter of 2022. Teslas also has two SUVs and two sedans, with a wide range of pricing points and sizes, The Model 3, Model Y, Model S, and Model X are apparently outselling many established gasoline-powered cars.[1]   But I can’t use a Tesla charger on my Prime because the nozzle doesn’t fit.

Plus, I personally refuse to buy anything from Elon Musk.

But other manufacturers are selling EVs, and I don’t know what drivers are doing for reliable charging. Maybe not taking road trips. Kia is second behind Tesla, with EV sales at 8,450 vehicles delivered in the first quarter of 2022.  Ford is third, with slightly over 7,400 electric vehicles delivered in the United States in the first quarter. They include the Ford Mustang Mach-E and the new electric Ford Lightning pickup has received 200,000 Lightning orders.

Hyundai is fourth, with 7,000 electric vehicles in the first quarter of 2022.

Some final thoughts on charging electric vehicles. Neither America nor Canada appears to be ready for prime time.  (Pun intended!) I was lucky to have a mostly gas vehicle. If I had relied on charging stations, I’d have been in trouble. As my tale of woe notes, they often aren’t working, don’t exist, are occupied, cost money but don’t tell you ahead of time how much, or aren’t located conveniently. In addition, NCL works on combatting child labor around the world, and EV battery production from China often involves materials mined in Congo where children work long hours in mines exposed to toxic chemicals. We support bills like that of Congressman Chris Smith (R-NJ) to ban the importation of “goods, wares, articles, or merchandise containing metals or minerals, processed, wholly or in part, by child labor or forced labor in the DRC.”

My experience prompted these questions.

  • despite the millions provided to US municipalities, why are so many stations not functioning?
  • Why can’t hotel chains like Marriott, Holiday Inn, Hilton and IHG guarantee working charging stations?
  • Who is accountable? The charging station companies were paid a lot of taxpayer money to put up devices that often don’t work?
  • Why can’t municipalities ensure their chargers are working? As I said, I never got a call back after my complaint to the city of Bangor.

My experience also prompted some possible solutions:

  • Require charging station manufacturers to guarantee that their stations are working and if they are not, are serviced quickly. They know exactly when a station is offline and if they have accepted municipal funds to build the station, they must be held accountable to keep it up and running or pay fines to the town or city.
  • Incentivize through taxes or otherwise major hotel chains and ensure that they build charging stations, post accurate information on how many charging stations they have, whether they are working and for what type of vehicle and what the cost will be to customers.
  • Rate the apps that give you nearby charging stations for accuracy – sure, there might be a station nearby, but is it in working order? is it occupied? Will it work for your vehicle?

The bottom line is that consumers don’t want to drive around for hours looking for working charging stations. The emphasis on building electric vehicles is admirable, but if we don’t vastly improve access to working charging stations, no one will want to own an electric car.

*Update* Since my trip I have enjoyed charging my car at daily at home and do in fact enjoy driving an electric car around town for my daily commute and errands!

[1] https://www.jdpower.com/cars/shopping-guides/what-percent-of-us-car-sales-are-electric

Guest Blog: Standardizing portions could help stem the obesity epidemic

By Deborah A. Cohen, MD, MPH

The past few decades have seen dramatic changes in the food environment and food behaviors, all resulting in the epidemics of obesity and diet-related chronic diseases.  About 72% of American adults are overweight or obese and more than half have diet-related chronic diseases. Our research shows that the food environment actually encourages people to eat impulsively and markets twice as much food as people need to maintain a healthy weight.  Our diets are largely influenced by the relative supply and availability of different food products, by marketing, and by other factors we aren’t even aware of.1-3  Restaurants are among the largest risk factors for a poor diet.

Here’s a rather shocking statistic: most Americans dine out between 4-5x per week and, on average, spend 55% of all their food dollars on meals and snacks away from home.4,5  The problem is that away-from-home meals are often inferior in nutritional quality to meals prepared at home – they tend to be higher in salt, fat, and calories, and lower in fruit, vegetables, and whole grains; they also typically include 2-3 times more calories than we need to maintain a healthy weight.6,7  Indeed, portion sizes have been increasing substantially over the past three decades.8

When people dine away from home, their ability to control portion sizes, and thus caloric intake, is limited. Studies demonstrate that we all eat more when we are served more. 9,10   As portion size increases, calories go up. The results are stunning:  Laboratory based studies in both adults,11,12 and children13,14 show that when larger portion sizes are served, calories go up as much as 30% with no differences in self-reported hunger.  So eating out – which we do a lot more than we used to – is a major contributor to weight gain and increases the risk of obesity and chronic diseases.6 Multiple studies support the association between frequency of meals consumed in restaurants and the risk for overweight.15-18

My research looks at how portion sizes can be made transparent and predictable with the hope that this would have an enormous benefit for America’s obesity crisis. Smaller, standardized portions are a practical and feasible solution to help stem the obesity epidemic.

Portion control has also proven to be an effective measure to reduce the amount – and therefore the harm – of alcohol consumption.19,20 Alcoholic beverages are classified by the percentage of alcohol content and the U.S. government defines a standard drink as containing 0.6 oz. of alcohol. Standard drink sizes are 12 ounces for a standard beer, 5 ounces for a glass of wine, and 1.5 ounce shot of 80 proof spirits.  These standard portion sizes allow us to measure a standard drink and to limit the risk of inebriation. Many states mandate that alcohol be served in standard portions; twelve states also require that larger portions of alcohol carry a higher price.21  Applying these principles to food could be an enormous aid, since people are not reliably able to judge what constitutes an appropriate individual portion just by looks.22-24 Standard portions are also a necessity for medications.  Many consider food as “medicine”, so applying portion standards to food is a natural extension that could improve health outcomes. That was our goal.

Piloting the Solution: Standardized Portions

Under a National Institutes of Health funded planning grant, my colleagues and I  developed guidelines for standard portions .  With input and guidance from an advisory board composed of nationally recognized nutrition researchers, we set calorie limits for meals at 700 calories each for lunch and dinner, 500 calories for breakfast and 200 calories for snacks.  We separated meal components into appetizers (150 calories), soups (150 calories), dressings and salads (150 calories), plain entrees (200 calories) for breakfast, lunch and dinner, mixed entrees (350 calories), non-starchy sides (100 calories), starchy sides (150 calories), beverages and desserts (100 calories).25

We conducted a pilot study with three local restaurants in Southern California. We incentivized these establishments to create an alternative menu to their usual offerings, providing meals in quantities that met the above caloric guidelines. We offered restaurants a $2000 participation fee as well as paying for all the costs of the menu development and printing, and purchasing gift cards to offer customers as part of the evaluation. The restaurants created new “Balanced Portions” menus, which included 6-8 items from their regular menu. The meals were not intended for weight loss purposes, but are only designed to prevent unintended overconsumption.

We began our pilot project by  asking restaurant managers to identify which menu items were the most popular. The project did not change any preparation or recipes. Not surprisingly, even though we would be reducing the quantity of some items served and increasing the quantity of others, none of the restaurants were interested in reducing the price of any item for offering less.

One restaurant did not want to change the price or the quantity, we plated the calorically set portions and then had them pack the remaining food for carry out.   (see Figure 1, top menu.) When we measured the original food quantities, in most cases the amounts served were double the guidelines for a single meal, so leftovers were sufficient for a second meal. The meal was marketed as “Dinner today, Lunch tomorrow”.

The other two pilot restaurants were not interested in packing up extra food, so they created an alternative menu by selecting menu items that already met the guidelines. The owners came up with new prices comparable to other selections on the menu. At yet another restaurant, the regular menu only included entrees and sides, so to get variety, people needed to order several large dishes. The new menu allowed people to get variety with one order. In all cases we requested that each meal contain at least one cup of vegetables. We piloted this with 3 restaurants: First Szechuan Wok, Dave’s Deli & Catering, and Delhi Belly. (Figure 1)

Once we verified the quantity of food to be plated as a serving size, we sent the meals out for calorimetry (measures calories) to verify that the calories would be <700.  All the meals met the criteria. We then held a training session for restaurant staff and provided written guidelines on food to be plated for each menu item. We provided restaurants with measuring cups and kitchen scales so they could meet the guidelines. The plates were full, as we generally increased the quantity of vegetables and reduced the quantity of meats and starchy sides. The restaurants all passed the training session.

Feedback from Customers. Once the menus were launched and made accessible to patrons, we invited customers to provide feedback on the menus and their experience and offered them gift cards from the restaurant for their participation, whether or not they ordered from the Balanced Portions Menu.

Overall, the feedback on the alternative Balanced Portions menus from customers was positive. We conducted in-person and phone interviews with 33 customers (56% ordered from the Balanced Portions menu) who dined at one of the three restaurants. Findings from the one-on-one interviews revealed that 16 of the 18 customers who ordered from the Balanced Portions expressed satisfaction with their meals and shared that they “would love” to see Balanced Portion menus offered at other restaurants. In addition, the availability of Balanced Portions menu may help them reduce food waste, maintain healthy eating habits, and meet recommended dietary guidelines. Interestingly, among those who ordered from the regular menu, one participant described the portions as “very generous” and more than half reported going home with leftovers.

However, some of the interviewees expressed concerns regarding cost and thought lowering the prices and offering more Balanced Portion menu options may encourage more people to opt for standardized portions. Some participants thought eliminating to-go options and offering smaller portions at lower prices would be most  appealing.

Adherence to Portion Sizes. We also assigned a research assistant (RA) to be a “secret shopper.” The RA ordered Balanced Portions meals to-go and then carefully measured each component with measuring cups and kitchen scales to determine adherence to the guidelines previously issued. In all but one case, the restaurants were adherent to the guidelines. At Delhi Belly they did give a little extra rice, and we advised the owner to be serve a bit less rice.

Conclusion: Our results were very promising.  We concluded that it is highly feasible for restaurants to offer meals with standard portions that reduce the risk of overconsumption, overweight and obesity associated with dining out. We also concluded that we will need more attention to the issue of Balanced Portions menus over time to inform future rollouts at a national level.  Furthermore, understanding the impact on customer attitudes and behavior will provide critical insights into how to scale this in the future. This research is a rewarding and promising first step, full of opportunities to effectively address the obesity crisis and its connection to eating food outside of home.

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  9. Rolls BJ, Roe LS, Meengs JS. Larger portion sizes lead to a sustained increase in energy intake over 2 days. J Am Diet Assoc. 2006;106(4):543-549. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=16567150
  10. Diliberti N, Bordi PL, Conklin MT, Roe LS, Rolls BJ. Increased portion size leads to increased energy intake in a restaurant meal. Obes Res. 2004;12(3):562-568. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15044675
  11. Rolls BJ, Morris EL, Roe LS. Portion size of food affects energy intake in normal-weight and overweight men and women. Am J Clin Nutr. 2002;76(6):1207-1213. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=12450884
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  23. Levitsky DA, Youn T. The more food young adults are served, the more they overeat. J Nutr. 2004;134(10):2546-2549. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15465745
  24. Wansink B, Painter JE, North J. Bottomless bowls: why visual cues of portion size may influence intake. Obes Res. 2005;13(1):93-100. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15761167
  25. Cohen DA, Story M, Economos C, Ty D, Martin S, Estrada E. Guidelines for Standard Portions in Away-From-Home Settings In:2023.

Unveiling the flaws in the 340B Drug Pricing Program: Hospitals, medical debt, and consumer struggles

Sally Greenberg

By Sally Greenberg, Chief Executive Officer

In 1992, Congress created the 340B Drug Pricing Program to help ensure vulnerable patients would be able to access medications they need but may not be able to afford. This program provides steeply discounted drugs to health care providers – mostly hospitals – serving low-income patients with the intent that the providers would pass those discounts along to patients. Unfortunately, that is not what is happening. The National Consumers League (NCL) is increasingly concerned about this program, especially as it relates to hospitals’ abusive and aggressive debt collection practices, and how those practices lead to consumer medical debt. A recent letter from a bipartisan group of Senators underscores hospitals’ role in this growing problem.

We find it particularly troubling that many hospitals benefiting from 340B are not only nonprofit entities but are designated as charity hospitals – supposedly caring for low income and indigent patients. A 2022 report by the Alliance for Integrity and Reform of 340B found that charity care spending for nearly two-thirds of 340B hospitals was less than the national average for similar hospitals. Further, a December 2019 Government Accountability Office (GAO) report found that “some nongovernmental hospitals that do not appear to meet the statutory requirements for program eligibility are participating in the 340B program and receiving discounted prices for drugs for which they may not be eligible.” One report found that 82% of nonprofit hospitals spent less on community programs than the value of their tax exemptions.

Consumers are not benefiting from the 340B program in the way Congress intended. A patient whose income is above 200 percent of the Federal Poverty Level (FPL) is expected to pay full price for a drug they receive at the hospital, even though the care center from which they are “buying” the drug did not pay full price for it. Hospitals participating in the 340B program saved an average of $11.8 million per year, according to a 2019 report from Beckers Hospital Review, and multiple studies have found that a majority of hospitals markup medicines between 200-500 percent. Under the current program, an individual who makes $29,200 per year has to pay that price.

What is even more alarming is the fact that if a patient can’t pay, the hospitals that have benefited enormously from discounted drugs intended for vulnerable patients are aggressively suing these same patients. This illustrates a major disconnect between the intent of the 340B program and the way it is operating today.

While estimates differ, medical debt is believed to cause more than 60 percent of bankruptcies in America. Most consumers facing medical debt did not end up in that situation because of bad decisions or profligate spending. Most have had some kind of injury or unexpected illness and don’t have insurance – or don’t have sufficient insurance – to cover their medical and hospital costs. Patients who need financial assistance should be processed when entering the hospital for medical care. Many are not given the chance to do so and as a result, can be sued for debt after services are rendered. Medical debt collection practices are debilitating for low-income consumers and can destroy their credit ratings, subjecting them to subprime rates and a never-ending spiral of debt.

Even if patients don’t start out poor, because of excessive fees, penalties, and other costs added onto what may or may not be actual medical debt on the part of patients, aggressive debt-collection practices can leave them destitute. Many don’t have funds to hire a lawyer, and if summoned, they often don’t know they need to actually go to court; in fact, sometimes debt collectors advise them not to show up in court. As a result, default judgments are filed against them, leading to garnishments of wages, and liens on homes, cars, and other properties. In 2019, the Journal of the American Medical Association studied the garnishment of wages by hospitals in the state of Virginia and found that 71% of the hospitals were nonprofit and the gross mean annual revenue of hospitals engaged in garnishments was $806 million, with 8,399 patients having wages garnished.

Below are just a few stories illustrating hospitals’ medical debt collection practices playing out in communities throughout the nation.

  • A woman in Knoxville, Tennessee, was diagnosed with cancer and underwent surgery and chemotherapy. Even though she had health insurance, she was left with almost $10,000 in medical bills that she couldn’t pay. Financial counselors told her she couldn’t schedule cancer checkup appointments with her doctor until she has a plan to pay her bills, according to a December 2022 story by NPR.
  • As reported by the Washington Post in May 2019, an investigation by the Baltimore Sun found that 46 hospitals in Maryland filed more than 132,000 lawsuits for unpaid medical bills from 2003 to 2008 and won at least $100 million in judgments. In some cases, hospitals added annual interest at twice the rate permitted for other types of debts or placed liens against patients’ homes.
  • The Washington Post reported in 2019 that the University of Virginia (UVA) Health System sued former patients more than 36,000 times for over $106 million over a six-year period. During that time, UVA’s Medical Center earned a $554 million profit and held stocks and other investments worth $1 billion. One of the patients the UVA Health System sued was Heather Waldron. Following emergency surgery and other treatment in 2017 to address an intestinal malformation, Waldron received a bill from the University of Virginia Health System for $164,000, more than twice what a commercial insurer would have paid for the care. When she was unable to pay, the UVA Health System pursued her with a lawsuit and a lien on the home she shared with her then-husband and five children. In the fall of 2019, the family lost their home, and the “financial disaster” contributed to Waldron and her husband divorcing earlier that year.

We support the critical role hospitals play in communities across the country and understand many dutifully provide charity care to those who cannot pay. However, we believe that if hospitals are designated charity entities and are receiving 340B discounts, they should be required to prove that those discounts have been passed along to patients. The current situation is unacceptable and merits an in-depth investigation and tightening up of the 340B rules. Charity hospitals should not be able to both claim 340B status and drag the very populations they are pledged to serve into debt collection proceedings, taking their homes, their cars, and their possessions in the process. Changes need to be made to ensure that only eligible hospitals are allowed to participate in the 340B program and that the deep discounts for medicines are passed along to patients, as Congress intended.

NCL mourns the passing of Rhoda Karpatkin

Sally Greenberg

By Sally Greenberg, Chief Executive Officer

The National Consumers League mourns the passing of consumer icon and President of Consumer Reports Rhoda Karpatkin.

Rhoda, who died last week, served as President of Consumer Reports (CR) and Consumers Union (CU)—having served for 26 years from 1974 to 2000.

I had the honor of working under Rhoda when I was hired in 1998 as Senior Product Safety Counsel in CU’s Washington office. I would use two nouns to describe Rhoda – fierceness and integrity. Rhoda maintained an unbending commitment to CR’s absolute independence from any outside influence or outside money, and that included corporations, individuals, labor unions, politicians, or media.

A visionary, Rhoda held to an unwavering moral compass. We all looked to her for ideas and guidance. She oversaw the work of Consumer Reports magazine in tumultuous times.

When I was hired, CR was being sued by two automakers whose cars did not pass CU’s rigorous safety testing. Consumer Reports won the lawsuit and neither auto company sells cars today.

Rhoda believed in a global consumer movement. She served two terms as president of Consumers International, a membership organization for consumer activist groups. She also helped to launch the Transatlantic Consumer Dialogue, which continues to this day. This past summer I represented NCL at the TACD meeting in Brussels. An inspiring organization, TACD brings together consumer groups from the U.S. and Europe to share strategies and collective initiatives.

In the name of Esther Peterson, the beloved and powerful consumer advisor to three presidents, Rhoda created a fellowship at CU’s Washington office. Gene Kimmelman, the director of the DC office, and I worked closely with Rhoda to bring candidates in for interviews and Rhoda loved the process and enjoyed coming to Washington from her Yonkers headquarters to participate in the interviews. She often asked candidates, “What are you reading?”—a question I have incorporated into my interviewing repertoire.

A central figure in the consumer movement of the 1970s, Rhoda nearly doubled the circulation of Consumer Reports to 4.2 million. By the time she left, its website was one of the largest paid subscription sites on the internet, with approximately 475,000 subscribers, according to the magazine. Rhoda grew the magazine’s operating budget and oversaw the redesign of the auto-test track and new research laboratories. She also supported the work of Dr. R. David Pittle, CU’s technical director, as we worked with Congress when product safety hazards made the headlines. Together we all tried to ensure that pro-consumer leaders had a place at federal safety agencies like the Consumer Product Safety Commission and the National Highway Traffic Safety Administration.

The consumer movement has had many great leaders, but Rhoda Karpatkin stands out for her kindness, integrity, and vision. I know I share the views of many of my colleagues who are deeply saddened to lose Rhoda. Her indelible influence lives on in all of us lucky enough to have worked with her.

Thank you, Rhoda. We will miss you.

New insurance schemes to carve out specialty drugs deserve skepticism and scrutiny

Sally Greenberg

By Sally Greenberg, Chief Executive Officer

Employers seeking to cut healthcare costs should remember this simple rule of thumb: If an offer to save money seems too good to be true, it usually is. That seems to be the case with offers to try “Alternative Funding Programs” or AFPs.  This is a devious but growing cottage industry, which promises to cut employer costs for specialty medicines.

Specialty medicines are used to treat complex, chronic conditions like cancer and rheumatoid arthritis; they are drugs often offered to some of the sickest patients. While they represent a mere 2 percent of prescriptions, they add up to half of the estimated $500 billion spent each year in the U.S. on drugs. Thus, specialty drugs are hefty contributors to self-funded employers’ health plan costs. (Source: optum.com)

One “solution” offered by third party vendors peddling AFPs is to remove coverage of specialty drugs from the employer’s formulary. This immediately renders those employees “uninsured” as far as coverage for their needed drugs goes. The AFP vendor then matches the newly uninsured employee with a patient assistance program offered by drug manufacturers and other charitable foundations. The patient’s co-pay is fully covered by the assistance program, the employer saves money, and the vendor takes a cut of the savings.

We think this so-called solution is underhanded and dangerous for patients.  It is also unethical and possibly illegal.

First, the charitable programs being mined by the AFP vendors are meant for the truly needy—those who are uninsured or underinsured. If these sources of funding are being drained by the AFPs, they won’t be available for patients who really need the assistance.

These programs are having a predictable effect:  drug manufacturers are starting to tighten the eligibility criteria for their charitable programs, limiting them to patients who are truly uninsured. That means the AFPs won’t be able to fulfill their promise to find alternative sources to pay for the medicine. The inevitable will happen:  patients will be forced to go back to their employers’ insurance, causing dangerous delays in treatment and eliminating any savings.

Critically, the AFP process interrupts and delays care for patients. One of the AFP vendors, aptly named SHARx, with a logo shaped like the predatory creature its name invokes, admits the process can take 2 to 6 weeks. While trying to enroll the previously insured patient in an assistance plan, they’ll “do as much as they can” to help a patient access their medicine, sometimes demanding they sign over power-of-attorney to their company. In practice, that means patients can be left in limbo with no coverage for a period of time.

How can an employer ethically expose their employees with serious health conditions to that risk? (Source: sharxplan.com)

There are also ERISA and IRS legal and compliance risks to self-insured employers, too, according to an analysis by Vivio, a Public Benefits Corporation (Source: viviohealth.com)

And by some accounts, the AFP vendors are taking a huge cut of any savings, as much as 25 percent, on top of the administrative costs employers must pay to implement the program. (Source: drugchannels.net)

Nonetheless, according to a 2022 survey, 10 percent of self-insured employers with at least 5,000 U.S. employees are using alternative funding vendors. Some 8 percent said they were planning to use them within two years and 19 percent are considering their use in three to five years. (Source: optum.com)

It is easy to initially discount AFP critics as defenders of unfettered drug pricing. However, even Optum, a subsidiary of leading health plan provider United Health Care, has sounded the alarm. They advise their clients “to look past the short-term sales pitch and consider longer-term financial implications, compliance risk and ethics of alternative funding programs.” (Source: optum.com)

We are raising the voice of consumers in support of efforts in Congress to rein in other dubious co-pay assistance schemes deployed by Pharmacy Benefit Managers such as co-pay maximizers and accumulators.  In this case, employers should take the lead in standing up for their employees’ health by refusing to open the door when third party AFP vendors come calling.

Guest Blog: The FABRIC act will address garment industry workplace concerns

By Rebecca Ballard

Last year the first ever federal fashion bill, The FABRIC Act, was introduced in Congress, and it will be reintroduced this September. However, the intersection between labor rights, legislation, and the garment industry is far from new. The industry has been tied to labor abuses since before our country’s founding; it was cotton that enabled the United States to reach global economic prominence, and issues with forced labor in fashion continue to this day. And it is not just labor concerns linked to fashion, but key labor achievements as well. Many of the labor laws that govern our lives and workplaces took root in the garment industry.

As a guest blogger for NCL and a longtime partner with the organization, I am excited to briefly share the fascinating history linking the garment industry and labor movements, some of the present-day issues in the industry, and even an opportunity to advocate for change this year.

The Industrial Revolution and the U.S. Fashion Industry

The industrial revolution gave rise to the fashion industry as we know it today, bringing innovation and affordable mass-produced items as well as widespread workplace labor abuses, sweatshop conditions, and pollution. In fact, the beginning of the U.S. industrial revolution is often cited as the opening of a textile mill in Pawtucket, Rhode Island, in 1793. During the Industrial Revolution we saw women, including recent immigrants, and children take jobs in textile mills to supplement family income. Many of these workers were exploited, toiling sometimes for 16 hours a day during high demand periods, for a subsistence income; all too often they were subject to wage theft.

But through this work, many women garment workers also achieved a measure of independence, leaving homes and families, and some used that newfound independence to join social activist movements and advocate for improved labor conditions. Female workers in Lowell, Massachusetts, for example, formed America’s first women’s union in the 1830s, which focused on maximum hours laws, including a 10 hour work day and higher wages, and they conducted one of the first major labor strikes in this nation’s history. Workers in New York’s sweatshops were victims of harassment, wage theft, and terrible conditions, and the International Ladies Garment Workers Union and Amalgamated Clothing Workers of America unions formed to demand labor reforms there in the early 1900s.

The Triangle Shirtwaist Factory Fire and Subsequent Labor Reforms 

Just as unions were gaining strength, the United States saw a devastating example of the incredible harms that can take place in the garment industry. Near closing time on March 25, 1911, the factory fire that broke out at the Triangle Shirtwaist Factory killed 146 workers, many of whom were immigrant women and girls. The building’s only fire escape building had collapsed during the rescue effort. Machinery and tables crushed workers, while locked doors trapped them, and there were only a few buckets of water to douse the flames. Firefighter ladders were too short to reach the 9th floor and safety nets ripped. The survivors from the 500-plus Triangle Shirtwaist Factory recounted the horrors they witnessed, including their fellow workers leaping to their deaths from the 9th floor rather than being burned alive. Some victims were as young as 14 years old.

In New York state, this tragedy prompted the transformation of the state’s labor and fire codes, thirty-six new state laws, and increased labor funding. The New Deal era under President Franklin Roosevelt saw adoption of similar legislation at the federal level nearly 20 years later with the support of some of these same reformers, like Frances Perkins who witnessed the Triangle Shirtwaist Factory fire herself and later became the Secretary of Labor under President Roosevelt. The Occupational Safety and Health Administration, country-wise fire and safety laws, and the Fair Labor Standards Act could be said to have arisen from laws enacted in New York after the Triangle Shirtwaist Factory fire.

Following the lead of women’s suffrage groups, and often in concert with women’s rights leaders, a number of trade unions formed to support the rights of garment workers. Roosevelt’s New Deal offered legal protection to unions, and through union gains and New Deal programs sweatshop conditions lessened and wages increased. However this brief period of reforms for workers in the US garment industry did not continue when the industry expanded and much of the industry moved abroad.

In addition to labor issues, the modern garment industry continues the environmental degradation that started during the industrial revolution. The industry today is playing a role in climate change and not on track to meet key climate goals and operate within planetary boundaries in its current form. Overproduction as well as over-purchasing are both extreme, and there are presently enough clothes on our planet to clothe six generations of people. Waste is often exported to other countries, hurting local economies and climates through waste colonialism. The industry continues to be powered by coal and uses toxic chemicals that are dangerous for workers, wearers, and our planet. Water usage is also highly problematic. For example, it takes over 2,000 liters of water to make just one t-shirt, around as much as one person drinks in three years. The water used in clothing creation, as well as clothing use, is often filled with microfibers that reach even the depths of our oceans and cause great harm to planetary ecosystems.

California Legislation

Sweatshops reemerged in the 1960s due to a range of forces in the U.S. and abroad: the changing retail industry, the growing global economy, increased contracting, and a large number of immigrant workers in the U.S. In the 1970s, manufacturers began outsourcing production to other countries to lower labor costs and employ a more compliant, non-union worker base. Despite increased consumption and a growing population, the number of U.S.-based garment workers dropped 37 percent, from 1.2 million in 1970 to 760,000 in 1995.

When sweatshops reemerged on U.S. soil they brought with them many horrific practices.  In California in the 1990s, the El Monte sweatshop, was subject to a raid that uncovered workers held behind fences surrounded by razor wire. These modern-day sweatshops exposed brutal conditions, with many tricked into accepting U.S. employment while living in other countries and once here being subject to debt bondage, threats of harm to them or their families, and violations of wage and hour codes. 

The 2021 California’s Garment Worker Protection Act (SB 62) enacted many statewide reforms for the industry in the state with the greatest number of garment workers. This landmark law aims to end wage theft and the payment of less than a minimum wage to garment workers by ending the piece rate of payment and creating liability for contractors for the full amount of unpaid wages and reimbursement of expenses, no matter how many layers of contracting are used. It also aims to enhance workplace safety by having garment workers no longer need to work at unsafe speeds to complete as many items as possible each day to reach a fair rate of pay.

The FABRIC Act

On the federal level, promising reforms include the first federal fashion industry bill, The Fashioning Accountability and Building Real Institution Change (FABRIC) Act, which was introduced in 2022 and will be reintroduced this September. A federal Lobby Day on September 12th is planned in partnership with national worker rights and sustainable fashion NGOs. The FABRIC Act follows in the footsteps of California’s SB62 by eliminating the piece rate and creating joint and several liability for violations of the law.  The FABRIC Act also creates a national garment manufacturing registry and incentivizes domestic production through a $40 million garment manufacturing grant program and reshoring tax credits. Anyone is welcome to be a part of the Lobby Day, and can sign up to volunteer here.