[00:00:00] Welcome to Discourse where we cut through the noise and make sense of the chaos. I'm your host, Wayne Unger. I'm a law professor and former Silicon Valley nerd, and I've spent years breaking down complex topics into digestible takeaways. And on this podcast, we'll take a deep dive into the pressing issues shaping our world in law, politics, technology, business and more. No echo chambers, no corporate influence. Just thoughtful analysis and respectful civic dialogue because understanding different perspectives isn't just important. It's necessary. Let's get started.

 All right. Welcome back to Discourse. I'm your host, Wayne Unger, and before we get started. Today we are recording today's episode at 4:30 PM on Tuesday, May 13th. And as always, things may have changed since. On today's episode, we're discussing prescription drug prices. You may have heard that President Donald Trump signed an executive order this week that targets prescription drug prices.

[00:01:00] Conservatives like Lauren Bobert in Congress spun Trump's executive order as a definitive move that will lower drug prices. But is that true? What does the executive order actually do when Bobert tweets quote, our president just lowered drug prices by 80% by executive order? Is that an accurate representation of what Trump has actually done this and more on today's episode of discourse?

But first, this message.

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To help us [00:02:00] continue this work commercial free, please join us as a subscriber and support us with a monthly monetary contribution. Visit discoursepod.org and click the support button today. Again, that's discourse pod.org, and click that support button today. Thank you.

Alright. By now, you have likely heard or have seen for yourself that Americans tend to pay significantly more for prescription drug prices in this country than foreign nationals pay in their countries. Now to illustrate this price difference, let's look at prep, also known as pre-exposure prophylaxis.

Prep refers to several medications that are used by HIV negative individuals to significantly reduce the risk of acquiring HIV through sexual contact or injection drug use. In other words, it is an [00:03:00]HIV prevention drug. It requires a prescription and the FDA first approved of the medication in a pill form in 2012 under a brand name called Truvada, and in 2019 the FDA approved a new formulation under the brand name Descovy. 

So let's focus on Truvada for a second. Generics of Truvada are now available, but the brand name drug is still quite expensive.

I used a website called pharmacy tracker.com to research a couple of these prices. And according to pharmacy tracker.com, Truvada under the name brand is priced at approximately $59 per tablet. For Truvada to be effective at preventing the transmission of HIV patients must take Truvada daily. This means a 30 day supply for [00:04:00] Truvada runs about $1,767 in the United States.

Of course, with health insurance in the United States, you likely would pay a lot less. But let's compare. In Italy the same drug, Truvada. That's the name brand, right? 677 Euros. At today's exchange rate, that's approximately $754 in Hungary, same drug, 350 Euros, or approximately $389 in France, same drug, Truvada 296 Euros.

I pulled these prices from a report titled Rapid Assessment on Access to Prep in the European Union countries that was funded by the health program of the European Union. I must note, of course, that EU countries have fundamentally different healthcare systems than the United States. So for example, in France, while the price is 296 [00:05:00] Euros for the brand name Truvada.

Patients are reimbursed in full under their healthcare system according to the same report.

And I'll try my best to compare apples to apples throughout this episode. But as a general disclaimer, my figures might be a little off given the differences in the healthcare systems in each country. That I am certainly not an expert in. And I also disclaim that the figures that I cite in this episode might be a little off due to several factors like exchange rates,

when the study was published, when the data was gathered, I. And other things like that. But back to Truvada. The figures that I mention are for the name brand Drug, Truvada, but there are generics available for Truvada. In Italy, where I said the name brand costs 677 Euros, Generics for the same drug run about 60 euros, and 60 euros is approximately 67 US dollars.

In the United [00:06:00] States, generic Truvada runs approximately $60. So in Hungary, generic Truvada is slightly more expensive at 130 Euros, which is about $144. These figures illustrate that at least with respect to the name brand, Truvada, there's a gross price difference between the United States and several European nations.

Now, that gross price difference, of course, assumes that there are no subsidies like health insurance in the United States or reimbursement programs in the European Union. What about one of the prep drugs that does not have a generic though? So let's look the injectable form that was most recently approved by the Food and Drug Administration.

Unlike Truvada, which you must take one pill daily, the injectable form is spaced apart between injections. To start, patients receive the first shot in month one. Second shot in month two, and [00:07:00] then every other month from there on out. So you'll get your third shot in month four, and then another one in month six and another one in month eight.

It is administered as a single 600 milligram or three milliliter dosage. So each time a patient receives the injection, the patient gets 600 milligrams. According to drugs.com, the price for a supply of three milliliters or 600 milligrams is approximately $4,300.

$4,300. This means for just one dose. Just one dose. The drug costs $4,300. It wholesales for approximately $3,700 per dose. Now, I disclaim that the numbers that I found for this drug were a bit all over the place, but in my research, I found some prices as high as $5,700 per dose.

Regardless, the prices illustrate my basic point, and that is the [00:08:00] name Brand for which no generic is available is very expensive in the United States. Annually, it could cost a patient upwards of $22,000, again, assuming no health insurance there to get some form of a discount. But what does it cost in other countries?

Same drug in the United Kingdom. The manufacturer markets this drug for 7,100 pounds for an annual supply, according to the NIH. Now, let me translate this. In the United Kingdom, an annual supply is approximately 9,400 US dollars. An annual supply in the United States, that same annual supply, $22,000 as I just said. That's a $12,600 difference for the exact same drug, and there's no generic on the market.[00:09:00]

According to the Canadian Journal of Health Technologies, this drug is expected to cost $11,252 per patient in the first year, and then $10,260 or so per patient in every subsequent year.

So let's take a look at another drug, one that it's more commonly known and used insulin. According to the world population review.com.

The cost of insulin in 2025 in the United States is approximately $100 per vial. It's $12 for the exact same in Canada, $7 and 50 cents in the United Kingdom, $7 in Australia. So if we were to rank the countries by the cost of insulin, the United States is actually first on that list.

Insulin is more expensive in the United States than all other countries that reported price for insulin. The country with the second highest price for insulin is [00:10:00] Chile at $21 and 50 cents. Translation that the country with the second highest price in the world for insulin is approximately one fifth of the price of insulin here in the United States.

So why does it cost so much more in the United States for a prescription drug? To answer this question, I came across an article published by Harvard Health or Harvard Medical School. And it was published last year. The article lists five top contenders for why prescription drugs cost so much more in the United States. They are number one drug manufacturer's, profit motive.

Number two, pharmacy benefit managers. I. Number three, cost sharing. Number four, legal maneuvers, and number five, direct to consumer advertising. Now, of those five, one stands out or one should stand out, which is the pharmacy benefit managers. I say it should stand out because that is unique to the United States.[00:11:00]

See, drug manufacturer's, profit motive, well, they're gonna have the same profit motive around the world, right? They're a for-profit entity, they're gonna have the same profit motive, so that that is constant around the world. Doesn't matter what country you're in. Cost sharing. Well, again, let's say that's constant as well.

I. Legal maneuvers. Yes, there's a difference in legal protections as you go from country to country. But given the complexity of that, let's set that aside. And direct to consumer advertising. Most countries do not allow pharmaceutical companies to advertise directly to the consumer, so perhaps that is an increased cost here in the United States.

The main difference, as I mentioned here in the United States, is pharmacy benefit managers, so let's discuss them. Pharmacy benefit managers or PBMs. Why PBMs specifically? Well, I. Mark Cuban helps explain why PBMs drive up the costs in the United States. And by [00:12:00] my account, PBMs are Cuban's number one gripe with the prescription drug industry in the United States.

So Mark Cuban several years ago launched something called Cost plus Drugs. It's a website where patients can obtain prescription drugs, many of them, if not all of them, actually generics at significantly lower price points. than getting them through an ordinary pharmacy. Cuban's history with prescription drugs dates back several years, kind of to that Affordable Care Act era.

See, in 2019, mark Cuban sought to create an alternative healthcare financing system. To the Affordable Care Act. And while that alternative never really picked up steam, it led him down a path of serious research into the prescription drug market. Cuban said that he began to wonder how generic drugs kept showing up on inventory shortage lists more and more.

One of the many things that Cuban took issue [00:13:00] with, as he learned more and more, was the lack of transparency. Why is it so difficult to find the price of a drug at your local pharmacy? Why is it that as a patient you don't know what your insurance provider is actually paying for the drug? This eventually led him to found cost plus drugs, where Cuban says he's all for transparency.

And it's true, if you go to the website. Cost plus drugs shows you what they pay for the drug and then the 15% markup to cover the other costs. So for example, that 15% markup covers things like the pharmacist. So $5 to the pharmacist to review the prescription, and then another $5 for shipping.

All prices, for all drugs, on cost plus are published on their website. Now I've been a customer of cost plus drugs in the past, and I can attest that it was often less expensive for me to [00:14:00] go through cost plus drugs, paying them retail and not using my health insurance, versus getting my script filled at Walgreens or CVS and using my healthcare insurance.

So for comparison, remember Truvada's generic pricing in the United States. I said it runs approximately $60 for a 30 day supply. The pricing for generic Truvada on cost plus drugs. Same dosage. Same quantity. $14. $14, that's it. $14 for generic Truvada. Like I said, cost plus drugs publishes their entire price list right there on the website.

So I was curious, which drugs get the largest discount if you go through cost plus drugs versus the normal retail price. Well, the top drug that I was able to find is the generic for, and I may mispronounce this Afinitor. That's the brand name, the drug name is [00:15:00] ever. Yeah, I really butchered that. Luckily I didn't take chemistry or pharmacy, but this drug is a targeted cancer drug for kidney, pancreas, breast, and brain cancers.

It runs approximately $3,040 or so for seven and a half milligrams at a 30 day supply. Cost plus drugs has it for 322 for a 10 milligram supply for 30 days, same drug, 10 milligrams, 30 day supply. It retails at $19,347. Guess what it is on cost plus drugs, $500. So let's say just round some numbers here, that is nearly a $19,000 difference.

Cost plus drugs simply charges a 15% markup from what they pay for the [00:16:00] drugs. And how are they able to do this? Well, they've cut out a lot of the middlemen, all the middlemen who are taking a portion of the money.

So back to pharmacy benefit managers.

PBMs control more than 90% of the prescription drug market in the United States according to an FTC report. Who are pharmacy benefit managers? You might not have heard of them per se, but maybe you've seen it on your health insurance card. They are CVS Caremark, express Scripts, and OptumRx. Now, those are the big three, the big three PBMs in the United States.

Each one of them is actually linked to a name that's more commonly recognized. CVS Caremark is owned by. Not surprisingly, CVS Health. Express Scripts is owned by Cigna. And OptumRx is owned by UnitedHealth Group. But it is likely that you have never heard of the PBMs, or if you have, perhaps it's a reasonable statement [00:17:00] to make that most Americans have no idea what PBMs do to understand this,

let's start by detailing the characters in the kind of supply chain for how does a prescription drug get to the patient and how does the money flow? We have seven major players in the prescription kind of ecosystem. They are health plan sponsors like employers, the health plans or the insurers, PBMs, drug manufacturers, wholesalers, pharmacies, and then the patients.

That's seven. So let's start with the plan sponsors for a second. In the United States, we know that employers are required to provide health insurance plans as part of a comprehensive benefits package, if they have to by law. These are the plan sponsors. Plan sponsors may share the cost and providing those health insurance benefits.

And this would be employees or patients [00:18:00] paying part of the premium, often deducted from the employee's paycheck. Now, plan sponsors likely combining some of its own funds with the premiums paid or deducted from the employee. Will they pay the health plans, the insurers, those are the insurance companies. So far this makes sense. Your employer buys the health insurance from the health insurer. Next we have PBMs. PBMs sit between the health plan, so the insurers, and the drug manufacturers. The PBMs do the negotiating and the transacting amongst all of the players, which I'll come back to here in a second.

Now, the pharmacies buy their drugs from a wholesaler, just like pretty much any retail company. And the wholesaler buys them from a drug manufacturer. And of course, you as a patient will you pick up your scripts from the pharmacies. So that's that side of the equation. In short, there are seven [00:19:00] players in the ecosystem, but let's look more closely at where and how the PBMs make their money for this, I'm going to play the short video from Stat News.

When you get sick, sometimes your doctor prescribes you a drug. This drug was developed by researchers at drug companies manufactured and distributed at pharmacies to help you get better. The process seems simple enough, but there's a lot of money baked into each step of bringing a new drug to market.

Drug makers want to recoup their costs, hence, the high sticker price of most new treatments. Paying out of pocket for these costs would be really financially disruptive, if not impossible for most people, which is where health insurance comes in. Health insurance works by spreading risk. A lot of people pitch in money AKA, pay a premium every year on a bet that they will get sick and need healthcare, and hopefully most will not.

Most health insurance plans provide coverage for some prescription drugs. So if you have a plan, you'll most likely pay less than the list price. So you pay for [00:20:00] your health insurance to help you out with paying for the drug and you pay for whatever health insurance doesn't cover. This is technically not so different from the way that you can get prescription drugs in other countries, many of which also use some form of cost sharing.

So what makes prescription drugs so much more expensive in the us? One big factor might be pharmacy benefit managers. Which only exists in the United States. We we have excellent health insurance.

The best PBMs are the middlemen between the drug makers, insurers, and pharmacies. In the 1960s, insurance companies started to offer prescription drug coverage to their members soon after PBMs arrived on the scene to help insurers manage the administration of these prescription drug claims. And because PBMs do a lot of admin stuff, for a lot of hospitals, insurers, and drug makers, they wield a lot of influence on the cost of drugs.

One of the ways PBMs influence drug costs is by creating [00:21:00] formularies. A formulary is a list of drugs and insurance company will cover. These lists are tiered typically with cheaper drugs in tiers one and two and more expensive drugs in tiers three and four. If two different drugs pretty much work the same.

Insurance companies will likely put the cheaper drug on the lower tier. Insurance covers more of the cost of the lower tier drugs, and thus consumers pay less for them. Drug makers want their medicines in tiers one or two. Because they're available to the most patients, they'll make the most sales. But how do they get their drugs?

In these tiers, they can offer the PBMA rebate or money back on a drug, which makes the drug cheaper for the insurance plan and moves it up on the formulary. So whenever a patient buys a drug in the top tiers, the PBM gets a rebate. The more expensive the list price of the drug, the higher the PBMs rebate tends to be.

There are two lines of thought here. On one hand, because PBMs have a lot of purchasing power, they work with hospitals and insurers. They have a lot of [00:22:00] people they can negotiate with. They can negotiate better prices for certain drugs, for everybody. On the other hand, there's not a lot of transparency in the relationship between drug makers and PBMs.

So we often don't know how much the actual rebates are. So if a drug maker offers a rebate to PBMs to lower the cost of a drug, AKA, raising it up on the formulary, we don't know how much of the rebate goes towards lowering the cost of the drug for the consumer. The PBM could be pocketing a higher amount of the rebate, and if drug makers have to offer rebates to PBMs to push their drugs up higher on the formulary, sometimes they have to raise the list price of their drugs to help cover the rebates.

So let's bring it all back. Drugs cost a lot of money to make health insurance costs money, even if you have insurance. If your drug is not covered by your plan, the cost you pay goes up. And if you don't have insurance, your drug might be available as a low cost generic. But for many brand name drugs, you might have to pay the list price.

On top [00:23:00] of all that, there's this complex formulary ranking system managed by PBMs that's pushing higher overall list prices for drugs. And it might be one clue why the cost of prescription drugs is so high for consumers today, but there's yet another side of this story, and it starts back at the beginning with the drug makers.

Well, did you get all that? Sorry, that was a four minute video from Stat News explaining how this all works. But let me recap what I took away from that clip just to reemphasize the points. If you weren't able to catch it from that video, which I know you didn't see, you only heard. So what I took away from that clip, pharmaceutical manufacturers want to sell their drugs. To sell those drugs, they need prescribers to write those scripts, and the patients are more likely to buy those drugs if they are covered by health insurance. So pharmaceutical manufacturers are incentivized to get their drugs on insurers' formulary. [00:24:00] That list, remember? Now the formulary list is divided into tier that reflect the cost of the drug.

A health insurance plans formulary might have three to five tiers. For instance, let's say for the purposes of our example that we have a formulary that's three tiers. Tier one is generic drugs. They have the lowest copays for the patient. Tier one might have kind of the preferred generic drugs and the non-preferred generic drugs.

So let's call these sub tiers, as I will call 'em. Tier two. Tier two is brand name drugs. These have slightly higher copays than tier one generics, but less than the super unique drugs. So let's say we have two SubT tiers once again; non-preferred and preferred name brand drugs.

The third tier [00:25:00] is the specialty drug tier. They have the highest copays. Of the three tiers because they are unique or they carry very high costs. As a drug manufacturer of a name brand drug, you likely want your name brand drug on the preferred list. Remember those sub tiers from that I just described?

Well, why is that? Because preferred name brand drugs are going to have lower copays than non-preferred name brand drugs. And if your drug has a lower copay. Then it's more likely that you'll sell more. So in this way, manufacturers want their drugs to be on preferred lists with respect to the formulary.

Since PBMs control the formulary list, what must a drug manufacturer do to get their drug on that preferred status? Well, the drug manufacturers are gonna have to pay the PBMs. Now, first, the [00:26:00] manufacturer's gonna pay the PBM just to have their drug on the formulary. Second, the manufacturer is likely going to pay the PBM more to have it on the preferred list versus the non-preferred list.

So drug manufacturers pay the PBMs in the form of rebates. So if you're still following me, the higher the rebate from the drug manufacturer, the more likely it becomes preferred and the more likely the drug manufacturer gets more sales and more profit. So higher rebates are more favorable to drug manufacturers in theory.

How might a drug manufacturer increase those rebates? It might, for instance. As the clip stated, increase the list price of a drug to cover that increase in the rebate. Okay? Whew. Now, that's one side of the equation. Let's look at the other. Who pays the pharmacy when you fill a prescription? [00:27:00] Your health insurance, right?

They pay. They pay. Well, maybe you have a copay. Most of the cost is paid for by your health insurance company unless you're on say, a high deductible plan, except, here's where PBMs come back into the picture. See, PBM started in the 1960s as that video said when insurance plans began covering prescription drugs.

If you are a health insurer. Why would you manage all the prescriptions for your policy holders or your patients when you could just outsource it? And that's what they did. PBMs manage the scripts for health insurers. So health insurers avoid the administrative burden of processing all of these scripts and paying out all of the parties involved.

So the health insurer, that health insurance company, well, they're collecting the premium from the plan sponsor, right? The employer who's providing you with that health insurance. Your employer might deduct a part of the, your premium [00:28:00] from your salary to help share the costs.

But the health insurer pays the PBM for managing its scripts. So it's really the PBM that is paying the pharmacy when you fill a script. The PBM is the middleman processing everything. On the pharmacy side, pBMs determine how much they will reimburse the pharmacies for each prescription for each drug.

Oh, but wait. PBMs also determine how much they will bill the health insurers. The health insurance plans for each script. So PBMs control both signs of the equation. They determine how much the pharmacies make and how much they bill the health insurance plans. The difference between those two, that's called the spread, guess who gets to keep the spread?

The PBM. If I've lost you, here's the bottom line. PBMs are incentivized to [00:29:00] increase the spread because the spread is one major way that the PBM makes money and PBMs are incentivized to pay the pharmacy the least amount possible, yet build the insurance company the highest amount possible so that they can maximize their spread.

Since PBMs sit between the drug manufacturers and the insurers, let's tie all of this together. Remember how PBMs negotiate with drug manufacturers and how they get these rebates. PBMs also negotiate rebates from the drug manufacturers so that the PBM gets a discount on the list price. Since PBMs keep a portion of those rebates, the higher the price of a covered drug, the steeper the potential discount.

Thus increasing the rebate. And that increases the PBMs revenue and the patients [00:30:00] are steered towards a higher price drug with higher rebates. So PBMs steer patients using the formulary list, pushing patients towards the preferred drugs in each tier, those that have higher rebates so that the PBM can make more money in this whole scheme.

Now what about generics? Here's how PBMs fit into the picture with respect to generic drugs. Since PBMs make more money, by number one, increasing the spread, that means paying the pharmacy the least amount possible while billing the insurance company the highest amount possible. And number two, via rebates from the drug manufacturers.

Are they actually incentivized to push generic drugs?

Generics of course, are cheaper, but the spread is less and so is the rebate. So PBMs make less per drug per script on a generic than they do on a name brand drug. In this way, PBMs are [00:31:00]incentivized to exclude generics from formulary lists, and PBMs are incentivized to charge higher copays for generic drugs to incentivize you,

patient or the consumer, to choose the name brand drug instead of the generic because the name brand will carry a lower copay, but it results in the PBMs making more money. So how is it that cost plus drugs, mark Cuban's company, how is it that I was paying less for my prescriptions with cost plus drugs without using my insurance

than I was paying with my insurance at say, Walgreens? That all of that comes from this messed up incentive structure that I just detailed. When patients use their prescription benefits to pay for generic medications, because those are generally not favored by the PBMs, the copays can sometimes [00:32:00] exceed the actual cost of the drug.

Oh, and by the way, the PBMs also make money by selling your data. Got all that? Well, it's a lot, isn't it? It's complicated. It's complex. There are too many players involved. I'll let you digest that and we'll be back after this to explain what Trump's executive order actually does and how we might lower prescription drug prices.

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 So does Trump's executive order actually lower prescription drug prices? It doesn't, at least not on its face. The text of the executive order doesn't actually lower the drug prices. See, section two of his executive order says that it is the policy of the United States that quote, Americans should not be forced to subsidize low cost prescription drugs in other developed countries. End quote. The Trump administration appears to have taken the perspective that prescription drug prices are higher in the United States because the United States is subsidizing the drugs for the rest of the world that benefit from those lower prices.

Is that what is actually going on though? Maybe, but let's [00:34:00] set aside the subsidy perspective and I say, let's set that aside. I. Because I just outlined the incentive structure here in the United States with the PBMs involved, that regardless of any subsidy rationale whether Americans are actually subsidizing the drugs for the rest of the world, PBMs still very much exist in the United States, and they are still incentivized to increase prescription drug prices as I previously outlined.

Trump's executive order does four main things. Number one, it directs the Secretary of Commerce and the US Trade Representative to take all actions to ensure foreign countries are not engaged in any act, policy, or practice that may be unreasonable or discriminatory, that has the effect of forcing American patients to pay for a disproportionate amount of the global pharmaceutical research and development.

Second, it directs the Secretary of Health and Human Services, or HHS to quote, [00:35:00] facilitate direct to consumer purchasing programs for pharmaceutical manufacturers that sell their products to Americans. At this kind of sub quote, most favored nation price end quote, it also orders the HHS secretary to communicate most favored nation price targets to pharmaceutical manufacturers.

To bring prices for Americans in line with comparably developed nations. End quote. And if pharmaceutical manufacturers do not significantly progress towards the most favored nation pricing according to the executive order, then the HHS secretary is to propose regulations that impose the most favored nation pricing.

It also orders, so this is number four. It orders the enforcement of the Sherman Antitrust Act and the Federal Trade Commission Act in this specific context. So the FTC for instance, must consider [00:36:00] whether there are any unfair or deceptive business practices going on here. That's the language pulled straight from the Federal Trade Commission Act.

That's it. That is all the executive order does. Is it a step in the right direction? Sure. Does it actually lower prices today? No, nothing about that executive order, order prices. So it's important to pay attention to what it doesn't do Nowhere in the executive order does it actually lower drug prices.

Why? Well, because the president does not have that power. Now, Congress has the authority to regulate interstate commerce per Article one, section eight of the United States Constitution. Now, while Congress has delegated a lot of authority, such as rule making authority, the ability to make regulations to the executive branch, the president cannot with the stroke of a pen on an executive order simply slash drug prices.

[00:37:00] He doesn't have the power to do so. So Lauren Boebert's tweet that I mentioned at the beginning and the other conservatives who are speaking the same narrative. Well, that is misleading at best or straight up, lying at worst. Now, by the way, president Biden signed an executive order that resembles Donald Trump's. Biden ordered his administration to enforce antitrust laws against prescription drug companies and everybody really in that ecosystem, and to promote generics over name brand drugs. But in fairness, Trump made moves during his first administration to tackle prescription drug prices. For instance, according to CNN, the first Trump administration sought to enact regulations that would ban the rebate scheme between drug manufacturers and PBMs.

Another regulation would've required some health centers in underserved communities to pass along the discounts that they receive on insulin [00:38:00] to their patients. So both parties have taken steps to decrease prescription drug prices using both regulation and legislation. For legislation, president Biden signed the Inflation reduction Act that among other things granted, the federal government, the authority to negotiate drug prices for Medicare.

Now, that of course, benefits those who are on Medicare, but the big pharma lobby killed the same plan that would've applied outside of the Medicare context. That negotiation of drug prices. So for that, the Inflation Reduction Act, Medicare prescription drug negotiation provision, no Republican supported it.

Here's my read. Both parties have supported and opposed proposals to lower prescription drug prices. Both parties have made attempts at lowering prescription drug prices in the past. [00:39:00] Both parties have reversed the other party's attempts at lowering prescription drug prices perhaps. Perhaps this is why we cannot get anywhere on lowering prescription drug prices.

There's just too much politicking involved, but somebody has been vocal and remarkably consistent on lowering drug prices. Senator Bernie Sanders. In the last 24 hours since Trump signed that executive order that we've been talking about, Bernie Sanders has called upon the Trump administration to support his legislation to lower prescription drug prices.

So let's take a look at what Bernie is proposing here. During the last Congress just to set the stage, Bernie and Senator Bill Cassidy, the Republican from Louisiana, introduced bipartisan legislation, actually multiple bills, in fact. So to outline them, Senate Bill 10 67, ensuring timely access [00:40:00]to Generics Act, Senate Bill 1114, expanding access to low Cost Generics Act, Senate Bill 1214, the Rare Act.

Then Senate Bill 1339, the Pharmacy Benefit Manager Reform Act. I'm just gonna highlight two of them. The second one, the expanding access to low cost generics Act. That would have changed how quickly a generic drug manufacturer could bring their generic to the market.

The fourth one. Titled The Pharmacy Benefit Manager Reform Act. That would have increased the transparency with respect to PBMs and their business practices by requiring certain disclosures and reporting such as the amounts paid, the total amounts received, et cetera. It also would have limited the spread pricing by regulating the prices charged on both sides of the equation, and it would have established the Health and Human [00:41:00] Services Department, or HHS, establish some level of oversight over PBMs, and of course it had other provisions as well. But these bills never went anywhere. Now, more recently, according to Forbes, even though these reforms have bipartisan support, guess who scuttled them this last year. First, in the house, the Speaker of the House, Mike Johnson, scuttled it.

The speaker pulled PBM reform from a continuing resolution aka budget bill under pressure from President Trump. In the Senate, Democrats proposed a bipartisan proposal trying to pass it by unanimous consent, which means having no members of the United States Senate object to it. But they were unsuccessful because it was blocked by Republican Senator Rick Scott of Florida.

Now, despite these setbacks, it appears that there [00:42:00] remains bipartisan support for reforming the system, and Congress is acting by holding hearings, proposing bills, receiving reports from the Federal Trade Commission, et cetera. The question is how, what will the reform look like and when? When will Congress pass something?

Answering those questions may be as complicated as the prescription drug ecosystem that I already described.

 That's it for today's episode of Discourse. Thank you for tuning in and being part of the conversation. You can catch future episodes of discourse wherever you get your podcasts. If you found this discussion insightful, be sure to subscribe, leave a review and share it with others who value thoughtful analysis over the noise.

You can also join the conversation by visiting discourse paw.org and following me on x and blue sky at Prof Unger for more insights and [00:43:00] updates. Until next time, keep thinking critically, stay curious and engage with respect. We'll see you soon.

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