(NewsNation) — Some members of Congress are trying to make prescription drugs cheaper, but they’re getting pushback from an industry most Americans have likely never heard of before.
Some Americans have to get their medications through a pharmacy benefit manager (PBM) that negotiates prices with drugmakers, often acting as middlemen between patients and pharmacies.
Critics argue the PBMs are jacking up their profits by artificially inflating prices, which has forced some patients, like Joshan Bajaj, to make tough choices.
Bajaj recently went back to school to start a career as a clinical counselor. But on top of his tuition, he pays up to $600 a month for medication and supplies to treat his diabetes. He says that means he won’t be able to finish his degree and afford treatment without finding extra work.
“It makes me really upset because I didn’t choose to be a diabetic, you know, it just happened to me,” Bajaj told NewsNation.
Lawmakers like Rep. Brett Guthrie, R-Ky., want to help people like Bajaj.
“Insulin prices are 30, 40, 50 dollars, but the list price is like $300,” Guthrie told NewsNation. “A PBM can charge you more for a co-pay than they actually pay for the drug. And that’s what we want to try to drill down.”
Guthrie thinks monitoring the middleman would lower prices for seniors on Medicare by ensuring they don’t have to pay extra based on where they get their care. Advocates also think it would bring more transparency to the way drug prices are set.
But the trade group for PBMs says their role is misunderstood.
“No one is forced to hire a PBM, but so many plan sponsors do because of that value that they’re delivering in trying to bring down the cost on behalf of the patients they represent,” J.C. Scott, president of the Pharmaceutical Care Management Association, said.
PBMs think the reforms could backfire because the goal of transparency could cost patients more money.
“It’s going to empower drug companies to potentially raise costs, and it’s going to take choice and flexibility out of the market,” Scott said.
Meanwhile, Bajaj is getting ready for his next semester of school. With two more years to go, he says he hopes lawmakers will do something soon that will make a difference.
“Any amount of help that they can do to lessen that burden will be greatly appreciated by millions of Americans,” Bajaj said.
Legislation that would change PBMs recently passed the House with overwhelming support from Republicans and Democrats. Now, it’s up to the Senate to review.