Tagged U.S. Congress

Longtime Crusader Against OxyContin Begins To See The Fruits Of Her Struggle

In the 15 years since she lost her son to a single OxyContin pill, Barbara Van Rooyan has had but one up-close look at the people representing the company that made it.

It was in a small courthouse in Abingdon, Va., where Van Rooyan and other relatives of OxyContin victims gathered for a sentencing hearing in 2007. Three executives of Purdue Pharma had pleaded guilty to federal charges related to their misbranding and marketing of the powerful opioid. The company had pleaded guilty as well.

Van Rooyan and the others in her group spoke during the sentencing, giving voice to their grief and their pain. They wanted the executives sent to jail for knowingly expanding an opioid crisis fast engulfing the country.

Instead, Purdue paid fines totaling $634 million. The executives served no time. The company was allowed to continue aggressively marketing its product, and the following year, sales of OxyContin reached $2 billion.

From 1999 to 2017, more than 700,000 people in the U.S. died of drug overdoses, according to the Centers for Disease Control and Prevention. In 2017, nearly 68% of the more than 70,000 recorded overdose deaths involved opioids.

“I never really thought a whole lot about evil before this all happened,” Van Rooyan said recently, seated on a couch in the living room of her Irvine, Calif., home. “But to see this kind of malevolence or disregard for human life — I don’t know what else to call it but evil.”

The outcome in that Virginia courthouse was a far cry from last week’s news of a tentative mass settlement of many of the 2,000-plus lawsuits against the company, which could total upward of $12 billion and result in Purdue’s dissolution.

The potential settlement amount would include $3 billion from the Sackler family, owners of Purdue, whose fortune is estimated at $13 billion. The family has amassed that money over the past two decades, largely by selling OxyContin, an opioid painkiller.

Van Rooyan’s Purdue experience is a story of deception, sadness and frustration — yet when she tells it now, she emits a surprising spark of energy. That’s because Van Rooyan, part of the unlikely group of citizens who repeatedly took flailing swings at Purdue Pharma, is watching the giant fall.

Van Rooyan, who has studied the cases against Purdue closely, sees the paradox in the proffered settlement: Much of the payout would be financed by profits from the continued sale of OxyContin, under a new company that would be formed following a Chapter 11 bankruptcy.

Van Rooyan says she treasures this photo of herself holding son Patrick shortly after he was born.  (Ana Venegas for KHN)

But in some regard, she said, Purdue Pharma’s complicity in the opioid crisis has finally emerged into the general public’s view. “The world really knows now. They get it,” she said. “The lid is off, and all this stuff is bubbling out.”

That wasn’t the case on the night of July 4, 2004, when Van Rooyan and her husband, Kirk, got the call that changed their world. Barbara, then a professor of counseling at Folsom Lake College near Sacramento, was told that her son, Patrick Stewart, lay in a San Diego hospital, in a medically induced coma from which he was unlikely to emerge.

Patrick, a graduate of Oak Ridge High School in El Dorado Hills, Calif., and San Diego State University, died at age 24. His friends told Barbara they had attended an Independence Day party at which someone offered her son an OxyContin pill, telling him it “was kind of like a muscle relaxant and it was FDA approved, so it was safe,” she said. Patrick, who had also consumed a couple of beers, was opioid intolerant and suffered respiratory failure in his sleep.

“At the time,” Van Rooyan said, “all I knew about Oxy was that Rush Limbaugh had been addicted to it.”

She was about to learn a lot more.

Van Rooyan channeled her grief through intense research into Oxy’s vast potential for damage despite the company’s sales pitches to the contrary. A slow-release pain treatment with a heavy dose of the narcotic oxycodone, it could be easily crushed or dissolved for a more intense and addictive high. Rampant abuse already had begun to be reported, particularly in the Appalachian area, author Beth Macy wrote in her national bestseller “Dopesick.”

Later in 2004, Van Rooyan found Ed Bisch, a Philadelphia man who had begun a website to expose Oxy abuse in the wake of his teenage son’s death. The following year, Van Rooyan and her husband, a plastic surgeon, petitioned the Food and Drug Administration to require that OxyContin be made more abuse-resistant, and that its use be strictly limited to severe pain.

“This was an exhausting process, which she and Kirk did as a labor of love to try to save others,” Bisch recalled.

Van Rooyan became the California arm of a grassroots movement known as RAPP — Relatives Against Purdue Pharma. The group, originally just four in number, protested at physician meetings funded by pharmaceutical companies and testified before Congress. Van Rooyan enlisted the help of U.S. Sen. Dianne Feinstein (D-Calif.), who wrote the FDA on her behalf and later sent Van Rooyan a letter of commendation.

In the 15 years since she lost her son, Van Rooyan has since channeled her grief into intense research about Oxy’s vast potential for damage and has become one of the trailblazers of the anti-OxyContin movement.  (Ana Venegas for KHN)

But most members of Congress did not reply to Van Rooyan’s letters, she said. The FDA said its review needed more time — which turned out to be eight years. By then, Purdue already had reformulated OxyContin to make it more abuse resistant and to renew its patent, but the FDA declined to restrict its use to managing severe pain.

Van Rooyan pressed on, but for a long while, the opioid crisis felt to her like a topic hiding in plain sight. And fighting Purdue while still grieving the loss of son Patrick was taking a toll.

“Her determination was tireless,” Bisch said, “but eventually the frustration burned us out.”

And then came the turn.

A rash of high-profile opioid overdoses and deaths, from actor Heath Ledger to Tom Petty to Prince, put the topic squarely in the public eye — and 15 years after the death of Van Rooyan’s son, Purdue Pharma and other drugmakers were suddenly on the run.

Van Rooyan tracks every development related to Purdue, including a lawsuit in New York that alleges members of the Sackler family have been offloading their fortunes into private or offshore accounts to shield them from a settlement.

But she’s not out for vengeance. Her goals have changed.

“Do I want the records to be public? Do I want these people to have their business shut down? Yes, I do,” she said. “But more than vindictiveness, I want that money of theirs to go to treatment and rehab. If that happens, something good can come out of it.”

Van Rooyan touches a painting she co-created with artist Nick Simon in memory of Patrick. She says art is part of what saved her in the aftermath of her son’s death.  (Ana Venegas for KHN)

If she has a regret, it is that the case in Virginia ended in 2007 with no more than a fine. “If that result had been different — if people had gone to jail — it could have changed the trajectory of this,” she said.

But momentum finally appears to be gathering, and Van Rooyan finds herself identified as one of the trailblazers of the anti-OxyContin movement. She spends little time dwelling on that. Instead, she quotes her younger son, Andrew, who told her, “We didn’t want any of this — this is just the hand we were dealt. We need to play the cards the best we can.”

“She’s just a really strong person,” said Kirk Van Rooyan, who has been with Barbara throughout the ordeal, though he is not Patrick’s biological father. “There have been times when I’d think to myself, ‘How would I be doing if I were in her shoes?’ And the answer usually is, ‘Not as well as she’s doing.’”

Van Rooyan, a longtime artist, now spends much of her time volunteering with veterans in Orange County, Calif., helping them get back into the workforce and using art therapy to help them express themselves.

The art is special to Van Rooyan, she said, because it is part of what saved her in the aftermath of her son’s death.

“Patrick was the one who suggested I take my first class,” she said. After a few delays, she finally enrolled. It was about a month before that Fourth of July in 2004.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! A quick programming note before we dive into the week that was absolutely jampacked with news: The Friday Breeze is going on a little hiatus (as yours truly explores Vietnam for a few weeks). I’ll be back in your inboxes Oct. 11, but you can always keep up to date through our host of other newsletters by adjusting your KHN email preferences here.

Now on to what you may have missed!

To be frank, if you missed Thursday’s Democratic presidential debate, you didn’t actually miss much in the way of developments on the candidates’ health care positions. But the sharp divide between the moderates (build upon existing framework) and progressives (sweeping systematic changes) was on display — confirming for perhaps the millionth time that health care will be front and center in the 2020 election.

The Washington Post: September Democratic Debate Highlights: Democrats Argue Over Health Care, Guns, Immigration

Beto O’Rourke drew praise from his rivals for how he handled the aftermath of the mass shooting in his hometown, El Paso, Texas — and also went big and bold on his gun control plan. “Hell, yes, we’re going to take your AR-15,” he said, in a declaration that in elections past would have been a nuclear bomb on a candidate’s campaign.

Los Angeles Times: Beto O’Rourke: ‘Hell, Yes, We’re Going to Take Your AR-15’

The “babies in cages” line is a go-to for many Democrats criticizing the Trump administration’s treatment of immigrant children in U.S. custody. It made for an awkward moment for former Vice President Joe Biden, who was part of the Obama administration that used the same facilities. “We didn’t lock people up in cages,” Biden said. “We didn’t separate families.” But a fact check shows that neither of those protestations is accurate.

The Associated Press Fact Check: Dems Draw Link Between Trump, El Paso Murders

And some people were left wondering after Thursday night: Where are the abortion questions? Considering all the developments that have occurred in the reproductive rights sphere over the past few months, debate watchers (and the candidates themselves!) were frustrated by the omission.

The New York Times: Marathon Democratic Debate Includes No Questions About Women’s Issues

Amid an ever-escalating outbreak of a lung disease that public health officials still haven’t gotten a handle on, President Donald Trump announced that he plans to ban flavored e-cigarettes. A look behind the scenes from Politico shows that first lady Melania Trump — who can be fairly reticent when it comes to public policy — was a driving force behind the president’s decision, which bucks traditional Republican thinking on the matter.

The New York Times: Trump Administration Plans to Ban Flavored E-Cigarettes

Politico: Melania Versus the Vapers

Trump’s decision was just the latest in a broader shift toward public health issues ahead of the 2020 elections. Voters routinely rank health care as high on their list of priorities, but Republicans have been grappling with the reality that Democrats have the edge on things like insurance and costs. So where does that leave them? Looking elsewhere to rack up victories and build talking points.

Politico: From Vaping to Opioids: Trump Redefines Health Care for 2020 Run

And in that vein, Trump startled California leaders this week when he sent a delegation of officials to check out the state’s homeless crisis. As you can imagine, the governors and mayors — who have been on the receiving end of verbal elbow throwing from the president over the issue — had a less-than-thrilled response to Trump’s interest. The message from the governor’s office: “If the president is willing to put serious solutions — with real investment — on the table, California stands ready to talk. He could start by ending his plans to cut food stamps, gut health care for low-income people, and scare immigrant families from accessing government services.”

The Washington Post: Trump Officials Get Look at Los Angeles Homeless Crisis

Los Angeles Times: Trump Team’s Homeless Tour of L.A. Sparks Suspicions, Concerns

Details of House Speaker Nancy Pelosi’s much-awaited drug-pricing plan dropped this week and the proposal looks far more aggressive than some had expected. It would allow Medicare to negotiate prices on the top costliest 250 drugs, and then those prices would be available to all consumers, not just Medicare beneficiaries.

The political takeaways:

— If Trump was bluffing about his own drug-pricing rhetoric, Pelosi is calling him on it. Some of the ideas — like pegging costs to what other countries pay for the drugs — are straight out of his playbook. She could also be looking to back Senate Republicans into a corner on the issue.

— But some people say the progressive plan is a signal that any bipartisan hopes should be curtailed. If Pelosi had thought she could get something through the Senate, the plan would have lined up closer to the anticipated blueprint. This way, she avoids a battle with the left flank of her chamber.

Politico: Pelosi Tries to Split Trump, Republicans Over Drug Pricing

The Washington Post: Pelosi Bill Aims to Negotiate Medicare Prices On Top 250 Drugs, Penalize Manufacturers That Don’t Comply

Purdue Pharma announced a tentative settlement with thousands of municipal governments nationwide and nearly two dozen states. Essentially, the company would be dissolved, a new one would be formed to sell OxyContin (with profits going to the plaintiffs) and Purdue would donate drugs for addiction treatment and overdose reversal. The Sackler family would be personally on the hook for $3 billion.

That last bit has been a sticking point with the states that aren’t interested in the settlement — many see that as far too low a penalty for the family. The states in favor of the deal like the idea of avoiding the uncertainty of a trial.

The New York Times: Purdue Pharma Tentatively Settles Thousands of Opioid Cases

For the first time in a decade, the number of uninsured Americans rose despite a strong economy. The Census Bureau report found an estimated 27.5 million people, 8.5% of the population, without coverage in 2018 (which is an increase of 1.9 million uninsured people, or half a percentage point). Democrats pounced on the numbers.

The Associated Press: Share of Uninsured Americans Rises for 1st Time in a Decade

With Congress back in session, Democrats were adamant about pushing Republicans into acting on gun control. Both Pelosi and Senate Minority Leader Chuck Schumer urged Trump to resist the NRA’s influence and “seize this moment,” because Senate Majority Leader Mitch McConnell has repeatedly said he is not interested in even thinking about legislation that Trump wouldn’t sign.

The New York Times: Pelosi and Schumer, in Push for Gun Safety Legislation, Urge Trump to Defy N.R.A.

Meanwhile, the gun lobby has been bombarding the White House, gaining access to Trump, and meeting with senior officials over the president’s expected gun violence proposal. But advocates on the other side can’t even get in the door.

Politico: Inside the Gun Lobby’s Push to Sway Trump

Several companies are being lauded for their decision to wade into the gun debate with their requests that consumers don’t open-carry firearms into the stores. Are they trying to play both sides? Because legal experts say they could go further than mere “requests,” and they’ve decided not to.

The New York Times: Stores Could Just Ban Guns, But Open-Carry Foes Back Requests as a Step

And I’m always a sucker for a good history lesson:

The New York Times: How Congress Passed an Assault Weapons Ban in 1994

So … it turns out Medicaid can function like a loan and not just government aid. For those of us who weren’t covering health policy in 1993 when then-President Bill Clinton signed the Medicaid Estate Recovery Program into law (making it mandatory that states seek repayment for Medicaid debts), The Atlantic offers a terrifying look at what happens when states come a-knockin. One woman received a 28-page, $198,660.26 itemized bill for “every Band-Aid, every can of Ensure” her mother used while on Medicaid.

The Atlantic: Medicaid Debt Can Cost You Your House

In the miscellaneous file for the week:

  • So, what’s up with all these blood pressure medication recalls? How did carcinogens get past the FDA’s regulation process? Well, it turns out that while the FDA has a rigorous approval process for new drugs, 90% of medications are generics. And those? They receive a lot less scrutiny.

Bloomberg: How Carcinogen-Tainted Generic Drug Valsartan Got Past the FDA

  • Frontline did an investigation into the Legionnaires’ disease outbreak linked to Flint’s water crisis and found that 115 people died of non-viral pneumonia. The official death count? 12.

PBS NewsHour: Flint’s Deadly Water

  • Any reader of the Breeze knows I can’t resist a superbug story, and this one is fairly traumatizing: It looks at how skilled nursing facilities — which are often understaffed and ill-equipped to handle rigorous quality control — have become the “dark underbelly” of drug-resistant infections.

The New York Times: A Breeding Ground for a Fatal Scourge: Nursing Homes

  • City leaders in Austin, Texas, found a workaround to strict regulations on providing public funding for abortions. If it can’t pay for the procedure itself, the city will help with auxiliary costs like transportation and child care.

Texas Tribune: Texas Told Cities They Couldn’t Fund Abortion Providers. So Austin Is Funding Abortion Access Instead.

  • Why would a gay New York City council member want to repeal a ban on conversion therapy? It’s for the greater good, he says.

The New York Times: New York City Is Ending a Ban on Gay Conversion Therapy. Here’s Why.

And that’s it from me for a bit! Have a great rest of the month!

KHN’s ‘What The Health?’: Despite Booming Economy, Uninsured Rate Ticks Up

Can’t see the audio player? Click here to listen on SoundCloud.

The annual report from the Census Bureau, released this week, found that 27.5 million Americans were without health insurance last year, an increase of nearly 2 million from 2017. The 0.5 percentage point increase in the uninsured rate — to 8.5% — was the first in a decade and came as unemployment and other economic indicators have been good.

Meanwhile, the Trump administration signaled that it is moving to ban flavored vaping liquid used in e-cigarettes. Companies making the products have been accused of marketing to underage users with flavors like mango and bubble gum.

And Congress is back from its summer break, with legislation to address rising prescription drug prices and surprise medical bills still on the agenda.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Tami Luhby of CNN and Rebecca Adams of CQ Roll Call.

Among the takeaways from this week’s podcast:

  • The Census Bureau’s report this week defied usual economic models. Normally, the more people employed, the more people insured.
  • Health advocates blame a variety of actions by the Trump administration for the lower rate of insured Americans. Those include policies intended to deter people from staying on or signing up for Medicaid; the elimination of the tax penalty for not having coverage; and the announcement that immigrants’ use of public benefits such as Medicaid could affect their ability to get a green card allowing them to live and work in the U.S.
  • The biggest surprise in the Census Bureau report was the increase in children without insurance. Coverage for kids has generally been a bipartisan goal on Capitol Hill. It’s not clear what caused that drop. It could just be a result of differences in how the survey was conducted, or it may be another sign of immigrants worried about whether using public insurance could lead to their deportation.
  • The administration’s announcement that it is moving forward on a ban of flavored vaping products comes as worries grow among parents and public health officials about an epidemic of lung problems around the country. Among those worried parents is first lady Melania Trump.
  • House Speaker Nancy Pelosi appears to be inching closer to releasing her plan to curb high drug prices. It’s not clear yet whether President Donald Trump will sign on to her effort. But Sen. Chuck Grassley (R-Iowa) is seeking support for his more modest plan instead, arguing to his Republican colleagues that if they don’t stand with him, they may be forced to accept Pelosi’s legislation if she manages to make a deal with the president.
  • Opponents of some of the legislation to curb surprise medical bills appear to have made progress over Congress’ August recess with a major advertising campaign saying the measures would hurt local hospitals and doctors. Advocates say the legislation is not dead, but the strong momentum it had is waning.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: Vox.com’s “This life-threatening pregnancy complication is the next frontier in the abortion debate,” by Anna North

Joanne Kenen: The New York Times’ “Nursing Homes Are a Breeding Ground for a Fatal Fungus,” by Matt Richtel and Andrew Jacobs

Rebecca Adams: Kaiser Health News’ “‘UVA Has Ruined Us’: Health System Sues Thousands Of Patients, Seizing Paychecks And Claiming Homes,” by Jay Hancock and Elizabeth Lucas

Tami Luhby: The New York Times’ “Bernie Sanders Went to Canada, and a Dream of ‘Medicare for All’ Flourished,” by Sydney Ember

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Congress Rakes In Millions From Drugmakers

Members of Congress raked in almost $4 million from pharmaceutical manufacturers and their trade groups in the first six months of 2019. Two members — Sen. Chris Coons (D-Del.) and Sen. Thom Tillis (R-N.C.) — each received over $100,000. Rep. Greg Walden (R-Ore.) is $5,000 shy of qualifying for the “million-dollar club,” a group of current members who’ve received $1 million or more since 2007.

The pharmaceutical industry has a long history of seeking to influence legislation by donating to the committees controlled by powerful members of Congress. As they return from recess and drug-pricing legislation comes into focus, find out how much your state’s representatives and senators took from the industry by examining KHN’s exclusive “Pharma Cash to Congress” feature.

Legislation To End Surprise Medical Bills Has High Public Support — In Both Parties

Nearly 8 in 10 Americans support legislation to protect people from surprise medical bills, a new poll from the Kaiser Family Foundation shows.

That support persisted no matter which party was asked: 84% of Democrats, 78% of independents and 71% of Republicans said they support surprise billing legislation, according to the poll. (Kaiser Health News is an editorially independent program of the foundation.)

Surprise bills are the unexpected ― and often expensive — charges patients receive after getting care from a doctor or hospital not in their insurance network. The issue has attracted a lot of attention in recent years, with ongoing projects like KHN-NPR’s “Bill of the Month” series and Vox’s look at emergency room bills illuminating the scope of the problem. The White House and both parties on Capitol Hill have expressed interest in finding ways to protect consumers from the practice.

But Congress has been bombarded by relentless attack ads and deep-pocketed lobbying against legislation that would end surprise billing.

And with lawmakers returning to work this week after the summer recess, some of the supporters of legislation on Capitol Hill worry that effort may destroy their chances of passing an effective law.

Critics claim that the primary legislation under consideration — in which a patient’s insurance would pay the out-of-network provider based on the average of what other doctors nearby are paid — would result in doctors and hospitals being paid less.

But the KFF poll found 57% of respondents support passing legislation to address the problem even after hearing the critics’ argument.

And as Democratic and Republican politicians alike discuss dismantling the ACA, whether through implementing a “Medicare for All” plan or ruling the existing law unconstitutional, the poll also found the public has some reservations about making drastic changes to the health system.

Ahead of Thursday night’s Democratic presidential debate, the poll found that 55% of Democrats and Democratic-leaning independents prefer a presidential candidate who wants to build on the ACA. About 40% said they prefer one who wants to replace it with a Medicare for All plan, which some advocates such as Democratic presidential candidate Sen. Bernie Sanders suggest would provide a single health plan for the entire country and replace all private insurance.

Those numbers are nearly identical to the findings in KFF’s last tracking poll in July.

KFF’s new poll showed the polarization that could undermine Democrats’ chances of unifying behind a single presidential candidate in 2020: 14% of Democrats and Democratic-leaning independents said they would vote only for a candidate who wants to replace the ACA with Medicare for All.

It also found 69% of all Americans support a government-administered public option health plan that consumers could opt into, a policy former Vice President Joe Biden included in his health plan. About 41% of Republicans said they support a public option.

That said, the poll shows many respondents do not see the difference between the policies that Democratic candidates are pitching: About 47% said a public option and a Medicare for All plan are similar.

The new poll also shows that support for the Affordable Care Act has hit an all-time high among Democrats, with 84% saying they view it favorably. The ACA became law in 2010.

KFF’s findings confirm that the Donald Trump presidency has galvanized Democratic support for the ACA, former President Barack Obama’s signature domestic policy. The percentage of Democrats who favor the law has increased by 11 percentage points since February 2017.

Among other policy questions, 70% of those surveyed said lowering prescription drug costs should be a major health care-related priority for Congress, and 69% said maintaining the ACA’s protections for those with preexisting conditions should be a top priority.

The KFF poll was conducted Sept. 3-8, with researchers surveying 1,205 adults by landline and cellphone, in English and Spanish. The margin of error is plus or minus 3 percentage points.

States Pass Record Number Of Laws To Reel In Drug Prices

Whether Congress will act this year to address the affordability of prescription drugs — a high priority among voters — remains uncertain. But states aren’t waiting.

So far this year, 33 states have enacted a record 51 laws to address drug prices, affordability and access. That tops the previous record of 45 laws enacted in 28 states set just last year, according to the National Academy for State Health Policy, a nonprofit advocacy group that develops model legislation and promotes such laws.

Among the new measures are those that authorize importing prescription drugs, screen for excessive price increases by drug companies and establish oversight boards to set the prices states will pay for drugs.

“Legislative activity in this area is escalating,” said Trish Riley, NASHP’s executive director. “This year, some states moved to launch programs that directly impact what they and consumers pay for high-cost drugs.”

And more laws could be coming before year’s end. Of the handful of states still in legislative session — including California, Massachusetts, Michigan, New Jersey, Ohio and Pennsylvania — debate continues on dozens of prescription drug bills. In New Jersey alone, some 20 proposed laws are under consideration.

“Both Democrat and Republican leaders have shown a willingness to pursue strong measures that help consumers but also protect state taxpayer dollars,” said Hemi Tewarson, director of the National Governors Association’s health programs.

Riley, Tewarson and others note, however, that states can go only so far in addressing rising drug prices, and that federal legislation would be necessary to have a major impact on the way the marketplace works.

Federal lawmakers are keeping a close eye on the state initiatives, Tewarson said, to gauge where legislative compromise may lie — even as Congress debates more than a dozen bills that target drug costs. Political divisiveness, a packed congressional schedule and a looming election year could stall momentum at the federal level.

The pharmaceutical industry has opposed most — though not all — state bills, said Priscilla VanderVeer, a spokeswoman for the Pharmaceutical Research and Manufacturers of America, the industry’s main trade group.

“We agree that what consumers now pay for drugs out-of-pocket is a serious problem,” said VanderVeer. “Many states have passed bills that look good on paper but that we don’t believe will save consumers money.”

Limiting Gag Rules For Pharmacists

At least 16 states have enacted 20 laws governing the behavior of pharmacy benefit managers. The so-called PBMs serve as middlemen among drugmakers, insurance companies and pharmacies, largely with pharmaceutical industry support.

Those laws add to the 28 passed in 2018. Most of the new laws ban “gag clauses” that some PBMs impose on pharmacists. The clauses, written into pharmacy contracts, stop pharmacists from discussing with customers whether a drug’s cash price would be lower than its out-of-pocket cost under insurance.

With widespread public outrage over gag clauses pushing states to act, federal lawmakers got the message. In October, Congress passed a federal law banning such clauses in PBM-pharmacy contracts nationwide and under the Medicare Part D prescription drug benefit. The Senate passed it 98-2.

Even so, many of this year’s PBM laws contain additional gag clause limitations that go beyond the 2018 federal law.

Importing Cheaper Drugs

Four states — Colorado, Florida, Maine and Vermont — this year have enacted measures to establish programs to import cheaper prescription drugs from Canada and, in Florida’s case, potentially other countries. Six other states are considering such legislation.

Medicines in Canada and other countries are less expensive because those nations negotiate directly with drugmakers to set prices.

“This is an area where states once feared to tread,” said Jane Horvath, a consultant who has advised Maryland and Oregon, among other states, on prescription drug policy. “Now both Republicans and Democrats view it as a way to infuse more price competition into the marketplace.”

Hurdles remain, however. A 2003 law allows states to import cheaper drugs from Canada but only if the federal Health and Human Services Department approves a state’s plan and certifies its safety. Between 2004 and 2009, the federal government halted nascent drug import efforts in five states.

Even so, momentum for importation has built in recent years in states and Congress as drug prices have continued to rise. And the Trump administration this summer threw its support behind the idea.

Florida Gov. Ron DeSantis, a Republican and close ally of President Donald Trump’s, signed his state’s measure into law on June 11, claiming he did so after Trump personally promised him the White House would back the initiative.

On July 31, HHS announced an “action plan” to “lay the foundation for safe importation of certain prescription drugs.” The plan includes a process to authorize state initiatives. It also requires formal regulatory review, including establishing Food and Drug Administration safety criteria. That process could take up to two years.

Two big problems remain: In the weeks since the announcement, the Canadian government has opposed any plan that would rely solely on Canada as a source of imported drugs. The pharmaceutical industry also opposes the plan.

Creating Drug Affordability Boards

Maryland and Maine enacted laws this year that establish state agencies to review the costs of drugs and take action against those whose price increases exceed a certain threshold.

New Jersey and Massachusetts are debating similar legislation this year.

Maryland’s law establishes a five-member board to review the list prices and costs of drugs purchased by the state and Maryland’s county and local governments. The board will probe drugs that increase in price by $3,000 or more per year and new medicines that enter the market costing $30,000 or more per year or over the course of treatment.

If approved by future legislation, upper payment limits on drugs with excessive price increases or annual costs would take effect in January 2022.

“My constituents have signaled loud and clear that bringing drug prices down is one of their top priorities,” said state Sen. Katherine Klausmeier, a Democrat representing Baltimore, who sponsored the legislation.

Maine’s law also establishes a five-member board. Beginning in 2021, the board will set annual spending targets for drugs purchased by the state and local governments.

Increasing Price Transparency

This year, four states — Colorado, Oregon, Texas and Washington — became the latest to enact laws requiring drug companies to provide information to states and consumers on the list prices of drugs and planned price increases.

The majority of states now have such transparency laws, and most post the data on public websites. The details vary, but all states with such laws seek to identify drugs with price increases above 10% or more a year, and drugs with price increases above set dollar values.

Oregon’s new law, for example, requires manufacturers to notify the state 60 days in advance of any planned increase of 10% or more in the price of brand-name drugs, and any 25% or greater increase in the price of generic drugs.

“That 60-days’ notice was very important to us,” said Rep. Andrea Salinas, chair of the Oregon House’s health committee, who represents Lake Oswego. “It gives doctors and patients advance notice and a chance to adjust and consider what to do.”

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! I come bearing bad news for anyone enjoying the slight decrease in D.C. traffic: Congress is back in full force next week. Although we have not had even a slight decrease in health news, I’m sure lawmakers will kick it up even further with gun control, surprise medical bills and, perennially, high drug costs on the expected docket.

For now, here’s what’s been going on during their final week of recess.

President Donald Trump has been coy about what exactly he’s put in his gun violence proposal, but one thing that seems likely: Both parties will be unhappy. (That, at least, seems a sure bet in these divided times.) What you can probably expect to see: an expedited death penalty process, changes to how troubled teens’ sealed records are shielded, and regulations — like “red flag” laws — centered on mental health.

Politico: Trump Prepares to Pitch Gun Proposals Few Really Want

Senate Majority Leader Mitch McConnell is sitting pretty on the sidelines at the moment, waiting to see what the president comes up with.

The Associated Press: McConnell Says He’s Waiting on Trump to Chart Path on Guns

Corporations, though, are taking matters into their own hands. Walgreens and CVS followed in Walmart’s footsteps this week in asking customers not to carry firearms openly in their stores. Walmart — which often tries to stay above the political fray — went further in announcing that it would stop selling ammunition for military-style assault rifles.

The New York Times: Walmart to Limit Ammunition Sales and Discourage ‘Open Carry’ of Guns in Stores

Reuters: Walgreens, CVS, Wegmans Ask Shoppers to Not Openly Carry Firearms

And in a bit of poor optics luck for Texas, a series of laws loosening gun regulations happened to take effect just a day after the state’s latest mass shooting.

Politico: Hours After Shooting Rampage, Texas Gun Laws Loosened

Also, if you want to terrify the bejesus out of yourself, dig into this piece about online forums with a toxic culture of hate that have become breeding grounds for mass shooters and where the inherent anonymity of the internet protects them from law enforcement.

The Wall Street Journal: ‘So What’s His Kill Count?’: The Toxic Online World Where Mass Shooters Thrive

In New York, health officials are eyeing vitamin E oil as a possible culprit in the mysterious vaping-related lung illness sweeping the country. The feds, however, aren’t putting their eggs in that particular basket and said that people should keep an “open mind” about the roots of the outbreak. “People need to realize that it is very probable that there are multiple causes,” said CDC Director Robert Redfield. But with a second death confirmed, officials are scrambling for answers.

Politico: Vitamin E Named as Primary Culprit in Vaping Illness, But Feds Urge Caution

An HHS internal watchdog report detailed the extent of psychological damage suffered by children affected by the “zero tolerance” separation policy. For children so young, it was hard for them to describe their emotional trauma. They were often reduced to complaints about their chest hurting, like “every heartbeat hurts” or “I can’t feel my heart.”

The Associated Press: ‘Can’t Feel My Heart:’ IG Says Separated Kids Traumatized

Crushing medical debt seems to be shaping the future of the country, and 2020 hopeful Sen. Bernie Sanders (I-Vt.) wants to change that. With a proposal that he only hinted at (i.e. did not give any solid details about how to pay for it), he said he would cancel $81 billion worth of medical debt for Americans.

The Washington Post: Sen. Bernie Sanders Teases Plan to Cancel $81 Billion in Americans’ Medical Debt

Meanwhile, despite the attention Sanders and the other progressive front-runners are giving proposals like “Medicare for All,” state lawmakers see defending the health law as the ace up their sleeves in tough elections. Virginia will be a major testing ground for that strategy as Democrats recently secured a big win on expanding Medicaid in the state. They could, however, be vulnerable to Republican messaging on high health care costs because the governor vetoed extensions for short-term plans.

Politico: Democrats Bet Big on Obamacare to Win Virginia Statehouse

So far, the implementation of Medicaid work requirements has been more crash and burn than the graceful transition many Republicans had likely hoped for. But Indiana seems on the path to becoming a model for other states as they add more restrictions to the program. I can explain it no better than Paige Winfield Cunningham at The Washington Post, who wrote: “If Arkansas and Kentucky were heavy-handed in imposing their work requirements, Indiana’s program is more like a tap on the shoulder, advocates argue.”

The Washington Post: Indiana Seeks to Impose Slower, Kinder Work Requirements on Medicaid Recipients

Meanwhile, over in Missouri, expansion advocates are hoping to follow the success of other states by getting the issue in front of voters rather than lawmakers.

The Hill: Advocates Launch Petition to Place Medicaid Expansion on 2020 Ballot in Missouri

The “Guaranteed to Make Everyone’s Blood Boil” award of the week goes to the article about how the Sacklers (the family that founded Purdue Pharma) could emerge from the opioid trials with their personal fortune intact.

The Washington Post: Sacklers Could Hold On to Most of Personal Fortune in Proposed Purdue Settlement

A cluster of HIV cases in West Virginia could be the canary in the coal mine that public health officials monitoring the opioid epidemic have been on the watch for. “This is the nightmare everyone is worried about,” said one expert about the outbreak that appears to be among the largest since one in Indiana’s Scott County four years ago.

Politico: ‘The Nightmare Everyone Is Worried About’: HIV Cases Tied to Opioids Spike in West Virginia County

In the miscellaneous file for the week:

• Reeling from persistent political attacks, Planned Parenthood has announced it will utilize telemedicine and a new app to reach young and rural patients who may have been affected by attempts to chip away at the organization.

The Wall Street Journal: Planned Parenthood to Expand App-Based Health Services to All 50 States

• We as a country are hooked on fast deliveries from Amazon, but there’s a human toll that flies under the radar that goes beyond workers’ pay. This ProPublica-New York Times story starts with the tragedy of a 9-month-old who died in an accident involving an Amazon delivery vehicle and doesn’t get any less heartbreaking as it goes on.

ProPublica/The New York Times: How Amazon Hooked America on Fast Delivery While Avoiding Responsibility for Crashes

• Be sure to check out this fantastic series about how America’s sick, poor and vulnerable will be the ones most affected by the growing climate crisis because they live in urban heat islands.

Howard Center for Investigative Journalism: Code Red: Baltimore’s Climate Divide

• On a much lighter note, scientists may have discovered a gene for left-handedness, which I just find fascinating and may make approximately 10% of my readers happy to know (mostly because it’s linked to having better verbal skills).

CNN: Scientists Identify the Genes Linked to Left-Handedness

• After millions of dollars, thousands of hours of manpower, tons of public outrage and a countless number of headlines from yours truly, the NYC measles outbreak has been declared officially over. The outbreaks in upstate New York still threaten the United States’ status as having eliminated the disease but, for now, public health officials are taking victories where they can get them.

The Washington Post: New York City Declares End to Largest Measles Outbreak in Nearly 30 Years

That’s it for me! Have a great weekend!

Watch: Five Things To Know About Hunger Among America’s Aging

One out of every 13 seniors in America struggles to get enough food to eat while the federal program intended to help hasn’t kept pace with the graying population.

Kaiser Health News Midwest editor/correspondent Laura Ungar explains what you need to know about this largely hidden problem.