September 30, 2020

Discounted Insulin and Epinephrine

How it could work

The Executive Order on Access to Affordable Life-saving Medications proposes to reduce the costs of insulin and injectable epinephrine to low-income patients. Federally Qualified Health Centers (FQHCs) that participate in the 340B program receive insulin and injectable epinephrine at significantly reduced prices, yet are required to charge patients a sliding scale fee based on their income, which may result in a price above the FQHC’s acquisition cost. This policy proposes that uninsured individuals or individuals with high unmet deductibles or high cost-sharing for these drugs should be able to purchase their life-saving medications at a cost aligned with the price that the FQHC purchases them at.  This policy is intended to benefit low-income patients, which the HHS Secretary can define by having: (1) a high cost sharing requirement for insulin or injectable epinephrine; (2) a high unmet deductible; or (3) no health care insurance.

What experts think

The expert panel was split on whether or not this executive order would reduce drug spending, though the majority stated that it would reduce spending, albeit minimally. Experts unanimously agreed that the order would have no effect on drug list prices; while the majority of experts agreed that there would be no change to drug net prices, two experts opined they would moderately decrease. The majority of the panel agreed that there would not be much change in access to drugs across any patient groups, with the exceptions of privately insured and uninsured patients and only then would there be a moderate increase in access.

The majority of the panel agreed that this executive order does not advance drug spending policy. Experts unanimously agreed that the magnitude of the drug spending impact would be a weakness of the executive order, another weakness would be the size of the affected patient population. The panel was split on whether the order’s ability to be implemented and its precedent-setting value would be a strength or an unknown.

How likely would this policy be to reduce drug spending?
Would Increase Drug Spending
Would Not Affect Drug Spending
Would Minimally Reduce Drug Spending
Would Moderately Reduce Drug Spending
Would Significantly Reduce Drug Spending
Would Substantially Reduce Drug Spending
How likely would this policy be to reduce drug prices?
Would Significantly Increase Drug Prices
Would Moderately Increase Drug Prices
Would Not Affect Drug Prices
Would Moderately Decrease Drug Prices
Would Significantly Decrease Drug Prices
List Prices
Net Prices
How likely would this policy be to increase patient drug access?
Would Significantly Reduce Drug Access
Would Moderately Reduce Drug Access
Would Not Affect Drug Access
Would Moderately Increase Drug Access
Would Significantly Increase Drug Access
Rare Disease
Large Patient Groups
How significant is this policy in the evolution of US drug spending policy?
Does Not Advance Drug Spending Policy
Minimally Advances Drug Spending Policy
Moderately Advances Drug Spending Policy
Significantly Advances Drug Spending Policy
Ground-Breaking Shift in Drug Spending Policy
What are the strengths and weaknesses of this policy?
Size of Affected Population
Evidence Base in Support of Policy
Precedent-Setting Value
Magnitude of Drug Spending Impact
How important are the following in your analysis of the policy's impact?
Not Important
A Little Important
Somewhat Important
Very Important
The existing FQHC sliding-scale income-based payment policies may limit the affected population
Unclear terms - low income, high unmet deductible, high cost-sharing
Unclear how the policy will be enforced

Considerations for policymakers

Experts highlighted three main considerations for policymakers. The executive order lacked clarity surrounding many of the key variables of the policy, including low-income, high unmet deductible, and high cost sharing. The policy also does not specify how it will be enforced. Finally, the current FQHC sliding-scale income-based payment policy may limit the potential affected patient population.