Not so fast, PBMs: You aren’t fooling consumers

By Robin Strongin, Senior Director of Health Policy

A recent op-ed, “It’s Time for Facts in the PBM Debate” by the president of one of the nation’s largest pharmacy benefit managers (PBMs), is at odds with the reality of what consumers are facing when we go to the pharmacy.

In his commentary, David Joyner paints a rosy picture of how the largest PBMs lower drug prices. Meanwhile, consumers across the country are being hit with higher out-of-pocket costs and a lack of understanding about what goes into the costs for their medicines. This opaque system results in consumers running into several issues trying to access more affordable drug options.

The PBMs aren’t fooling anyone.

In Joyner’s own company, a whistleblower brought suit over the PBM’s scheme to keep lower-cost generics off its formularies for Medicare beneficiaries, pushing seniors to more expensive drugs (for which the PBM had negotiated higher profits for itself). The whistleblower said she was told by company executives that the financial benefits of this manipulation outweighed the possibility of getting caught.

More recently, community pharmacies in Iowa filed a lawsuit against CVS Health and its Caremark PBM claiming that they violated antitrust laws and illegally collected fees from pharmacies filling Medicare prescriptions. We’ve seen this behavior often force trusted, and long-established local pharmacies out of business.

What’s most concerning is that such questionable PBM behavior can have tragic results beyond pharmacy closures. In Wisconsin earlier this year, a young man with severe asthma died after he was informed at the pharmacy that his inhaler was no longer covered by insurance and he couldn’t afford the hefty out-of-pocket cost.

We can’t let this happen to another person. Consumers deserve more transparency. They deserve accountability in this middlemen PBM system. Most of all, we all deserve better than to be inundated with large PBM falsehoods.

Even as these mega-PBMs assure us that they are patient advocates, they are fighting tooth and nail in Congress and state legislatures to block measures that would take the necessary steps to ensure that consumers – and not the PBMs themselves – actually benefit.

Those are the facts in the big PBM debate.

Nancy Glick

It’s time to care about obesity care

Nancy GlickBy Nancy Glick, Director of Food and Nutrition Policy

Every year, the calendar is full of national health observances – special months, weeks and days that raise awareness of serious diseases and health issues. While all are valuable to advance the health of the Americans, Obesity Care Week taking place March 4-8 is especially significant.

Why?  Because even though the adult obesity rate now exceeds 42 percent – the highest level ever recorded – obesity is still viewed as a problem of lack of willpower, too many health professionals act in discriminatory ways based on people’s size, and those seeking obesity care often face exclusions in insurance plans or restrictive practices that delay or deny treatment.

The consequence is that that only 10 percent of people with obesity get help from medical professionals, meaning the disease remains largely undiagnosed and undertreated.

It doesn’t have to be this way. There are a variety of safe and effective treatment options. And medical societies, including the American Medical Association (AMA), agree that obesity is a complex disease requiring ongoing quality care. The key is for society – including health professionals, insurers and policymakers – to care about obesity and agree that treatment matters. Here are the reasons why.

It is long past time for health professionals, employers, insurers, policymakers and the American public to care about obesity and work collectively to break down the barriers that prevent people from accessing proper care and treatment. This is the purpose of Obesity Care Week – to shine a light on a disease that no one has wanted to talk or think about and shift the way society views obesity and treats the disease.

Obesity Care Week is also an opportunity to call attention to the first Obesity Bill of Rights for the nation, developed by NCL and the National Council on Aging in consultation with leading obesity specialists and issued in January 2024. Starting with the recognition that obesity is a treatable disease, the Obesity Bill of Rights establishes eight essential rights so adults will receive the same level of attention and care as those with other chronic conditions and have access to all treatments deemed appropriate by their health providers. Now is the time to advance changes in federal, state, and employer policies that will ensure these rights are incorporated into medical practice.

More information about the Obesity Bill of Rights is available at: www.right2obesitycare.org.

The 340B drug discount program should be helping patients in need, not boosting pharmacy chain profits

By Sally Greenberg, Chief Executive Officer, National Consumers League

The federal 340B drug discount program is a worthy and critical program. Created by Congress in 1992, it mandates that pharmaceutical manufacturers participating in the Medicaid program must offer prescription medicines at discounted rates to community health centers and safety-net hospitals serving low-income and uninsured patients. Over the years, this program has given vulnerable patients access to the drugs they need and freed up resources for the qualified facilities to offer more health care services to indigent communities.

Over the past decade or so, however, this valuable program has been increasingly corporatized by for profit entities known to increase costs for consumers including middlemen like pharmacy benefit managers and pharmacy chains. Too many of the dollars circulating through the 340B program are benefiting the well-off and for-profit corporations, instead of consumers with significant health and financial needs. News stories have shined a spotlight on big health systems using the program to bolster profits, while hallowing out critical resources in underserved areas. However, more attention needs to be given to the billions of 340B dollars going to major pharmacy chains like CVS, Walgreens, Walmart and Rite-Aid that are not benefiting the patients this program is intended to serve. Increasingly, however, policymakers at the federal and state level are suggesting bailing out these for-profit entities under the guides of “contract pharmacy” legislation.

Here’s the problem: In 2010, the federal government issued guidelines allowing 340B-eligible health providers to contract with for-profit retail pharmacies to dispense medications, with virtually no rules or safeguards. Since that time, the number of pharmacies participating in the 340B program has grown from 789 in 2009 to over 25,000 today. If this meant more access to affordable drugs for consumer, that would be one thing, but this has not been the case. As contract pharmacies have increased, so too has consumer challenges affording their medicines, nearly in parallel. For example:

  • Even though 340B contract pharmacies are receiving drugs at discounted prices, there is no evidence they are passing those savings onto consumers. One analysis from the respected IQVIA firm found that 340B discounts were shared with consumers in only 1.5 percent of eligible pharmacy claims.
  • Although the 340B program is intended to benefit underserved, vulnerable communities with high proportions of poor and uninsured patients, hospitals in the program are contracting with pharmacies that are not, in fact, in areas afflicted with poverty and a scarcity of health care services.
  • The vast majority of 340B contract pharmacy arrangements are with the aforementioned big national chains like CVS and Walgreens, which are enjoying enormous profits as a result of their participation in the drug discount program. Contract pharmacies collected an estimated $13 billion in gross profits in 2018, with a 72% profit margin on 340B drugs (because they are getting those drugs at a steep discount, which they don’t share with consumers). Needless to say, fattening corporate pharmacy profits should not be this program’s mission.

Contract pharmacy abuse of the 340B program has not gone unnoticed by policymakers in Washington. In January 2024, leaders in the U.S. Senate questioned CVS Health and Walgreens as part of as part of an ongoing investigation into how health care entities use and generate revenue from the 340B Drug Pricing Program. The Government Accountability Office (GAO) and the Department of Health and Human Service Office of the Inspector General (OIG), also highlighted issues with the program’s integrity as it relates to contract pharmacy use. 340B is in desperate need of transparency and oversight, not unfettered expansion.

Yet that is exactly what is happening in some U.S. states. This matter is taking on a greater urgency now as several states are contemplating legislation that doubles down on the problem instead of fixing it. Consumers would be shocked to learn their state representatives are ushering through changes that would further solidify the profitable role these large corporate contract pharmacies are playing in the abused 340B program. Policymakers at the state and federal level need to address a fundamental question – where do 340B savings go? And when the answer is to corporate pharmacy giants – not patients – it’s time to reconsider ill-conceived policies giving contract pharmacies even more access to 340B drug discounts.

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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.

Consumer struggles with Native American healthcare

By Sam Sears, Health Policy Associate, National Consumers League

My name is Sam Sears, and I am the new Health Policy Associate working at the National Consumers League. I am excited to be working with Robin, Sally, and the rest of the staff at NCL. Consumer issues regarding health care, specifically access and confidence, are wide-reaching and I am thrilled to be able to lend my growing expertise and experience to support the cause and NCL.

I always thought I would end up in healthcare, but my younger self had always envisioned my work with a much more narrowed focus. Academically, my background is in policy and gender studies, where I focused on equal protections for women and queer, specifically related to intimate partner violence and protections and reproductive justice. After graduation, I worked as a barista while also taking placements through a temp agency here in DC, focusing on nonprofits and advocacy organizations. It was, in part, due to the temp placements that I found myself working on broader health policy issues such as the 340B Drug Pricing program and health care access for individuals.

Before joining NCL, I worked at the National Council of Urban Indian Health (NCUIH) for two years, where I was able to learn quite a bit about the healthcare delivery system for Native Americans and the barriers to access that they often face. While NCUIH’s focus is centered on ensuring that Native Americans living in urban settings have access to quality, accessible, and culturally competent health services, much of the work is done collaboratively with other advocates and organizations working within the space. Because of this, my work at NCUIH often was encompassing issues facing the larger community.

Upon joining NCL, I realized that a prominent problem for Native Americans is a much larger area of concern for all Americans and their healthcare – the pervasive and misleading Medicare Advantage plan advertisements seen on television. In fact, in a letter to Centers for Medicaid and Medicare Services (CMS) and Dr. Brooks-LaSure, the CMS Tribal Technical Advisory Group, a group of 17 representatives comprised of elected Tribal leaders or appointed representatives and representatives of national Indian organizations headquartered in DC, highlighted how Medicare Advantage (MA) plans have been “aggressive and invasive when marketing their plans”.

A Kaiser Family Foundation report on the 1,200 unique ads, mostly for MA plans, aired during the enrollment window found that 27% led beneficiaries into thinking they were being recruited for traditional Medicare plans. For Native Americans, this aggressive marketing has led people to enroll in plans that do not include local Indian Health Service providers, meaning they lose coverage and no longer able to go to the doctors they trust to care for them in a culturally competent manner. This confusion is not limited to just Native Americans, as Dr. Brooks-LaSure has stated previously.

It’s important to note that CMS has been addressing the misinformation and confusion from these ads. In April of 2023, the agency released a final rule regarding Medicare Advantage marketing and communications, amongst other Medicare part plans and related topics. Specifically, CMS must now pre-approve all television MA plan advertisements that will air during the open enrollment period, minimizing the opportunity for misinformation and predatory practices within the ads. CMS has also significantly increased its ability to investigate complaints about misleading agents and advertisements. This regulation, while large and with rolling applicability dates, will apply to the 2024 contract year for MA plan marketing and communication, meaning that the open and re-enrollment period at the tail end of the 2024 calendar year will be drastically different.

As I stated earlier, many of the issues that I had worked on while with NCUIH are also applicable to the broader population and community who struggle with access to healthcare. So, I am excited to be able to continue to work on these consumer issues with NCL. And I am eager to see how NCL could support and expand on the work I’ve been able to touch on through my other positions.

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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.

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

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.