Market access on the Hill: what’s possible in the next two years

In the wake of a new presidential administration and Congress, leaders are faced with their constituents’ healthcare concerns, and how they can address rising drug costs, limited plan choices, and the implementation of recent legislation including the Inflation Reduction Act.

Healthcare policy expert Joel White, president of Horizon Government Affairs, will be addressing the market access audience at the upcoming Hubs and Specialty Pharmacy Models conference specifically to provide an update on the IRA.

He said of the current landscape, “On the consumer side, we see really high premiums, fewer plan choices, higher out-of-pocket costs, more restrictive formularies, and more.” This in turn will affect how the Trump administration responds. “In two years, in the next [mid-term] election, Trump and congressional Republicans will own that market. They will own the premium increases and any disruption that consumers and patients are feeling in the Part D market.”

Joel White, president of Horizon Government Affairs

White explained this is leading to some discussion on how to deal with tightly managed formularies, drug pricing, and, most immediately, how to implement the IRA law, which has embedded deadlines.

Outside of implementation, White said DC insiders are discussing the IRA from a different angle--is it working well, should it continue as is, or should it scale back because it’s a Biden/Democrat program? Or should it be supercharged to really make it a Trump program?

PBM reform: a bipartisan effort

White also provided some DC-based thinking around other hot topics for market access professionals. Pharmacy Benefit Managers (PBMs) have come under scrutiny for their role in the prescription drug distribution system for quite some time. Most recently, an FTC report highlighted concerns about PBM practices, particularly regarding generic products. White observed:

"Their words [were] that PBMs were increasing costs significantly for employers, their employees, and the healthcare system broadly. This adds to the narrative that we've heard, at least for the past several years, that the people hired to negotiate lower drug prices are frustrating consumers."

White said that no matter what side of the PBM issue you are on, it has created a problem for voters, and therefore, politicians are responding with bipartisan support for PBM reform legislation. This could take the form of delinking reimbursement from drug list prices, rebate pass-throughs to consumers, bans on spread pricing, and maybe competitive market reforms around PBM ownership of specialty pharmacies or referral patterns, suggested White. In fact, White said that by the time of the ACCESS USA conference, we could see a PBM reform bill make its way to the president.

White also said that market access professionals should keep their eye on the biosimilars and white-labeling space. He said that Congress members are generally disappointed that biosimilars didn’t lower costs and are encouraged by white-label efforts.

Looking ahead

As noted, White predicts some form of PBM reform will land on the president’s desk around mid-March. Next up, would be a large budget bill package in April or May, though he says that’s pretty optimistic and could be before the end of the year.

However, the next wave of legislation would take a couple of years due to the complexity of the issues, as well as the bipartisan approach necessary.

“Getting access, getting affordability, getting the product covered and paid for in a way that helps the patient is really complicated and these are issues where you have competing interests and competing finances,” said White. He does predict that we will see a new patient Bill of Rights, or insurance reform starting this year, with a two-to-three-year roll-out.

Learn more at our upcoming conference.

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