Axios Vitals

A briefcase with a red cross on the front.
May 17, 2018

Good morning ... A federal appeals court in Washington yesterday helped bring the lawsuit over the Affordable Care Act's cost-sharing payments closer to an end — while a federal trial court in Texas helped advance another lawsuit over the constitutionality of the individual mandate.

The sun will burn out before we're done litigating the ACA in the courts.

1 big thing: Who pays for prescription drugs

Data: Peterson-Kaiser Health System Tracker; Graphic: Chris Canipe/Axios
Data: Peterson-Kaiser Health System Tracker; Graphic: Chris Canipe/Axios

The rising cost of prescription drugs is mostly falling to insurance companies and the government, while patients' out-of-pocket spending is holding steady.

That contradicts drugmakers' arguments that the outrage over rising drug prices has intensified because consumers are shouldering more of those costs on their own.

Yes, but: Overall, insurers and employers are shifting more costs onto employees through higher deductibles and copays. And even though they're absorbing the bulk of the increase in drug spending themselves, some consumers are paying significantly more.

  • Out-of-pocket costs for Medicare Part D grew by 13% between 2013 and 2016, according to Avalere. Over the same time period, the number of seniors who reached the "catastrophic" threshold for out-of-pocket spending rose by about 300,000.

What they're saying: Experts tell Axios' Caitlin Owens that there are still plenty of reasons to be angry about drug costs.

  • "At a minimum it says that the [average out-of-pocket] spending on drugs is not the only thing driving anger," said American Enterprise Institute's Ben Ippolito. "It could very well be that we have more people in the high spending category, and that engenders sympathy, etc."

Read more.

2. Opioids: 34 bills, 6 lawsuits, 1 new treatment

The policy and political response to the opioid epidemic is plowing ahead on all fronts.

In Congress: The House Energy and Commerce Committee is meeting this morning to mark up 34 bills to address the opioid crisis, after unanimously advancing another 25 opioid bills last week.

A full list and summary of each bill is available here. Many of them are pretty minor — simply asking for studies or reports — but here are some of the substantive highlights of what these bills would do:

  • Allow more providers to prescribe medication-assisted therapy, and ensure they can treat more patients.
  • Allow Medicaid to pay for up to a month of care in large mental health treatment facilities.
  • Require more prescription monitoring in Medicaid.
  • Give the FDA more power to seize shipments of illegal drugs at the border.

Meanwhile, the Ways and Means Committee passed its own opioid measures yesterday, including this one designed to stop shipments of fentanyl and other illegal drugs. Sen. Rob Portman, however, complained that it's a "weaker alternative" to a bill he sponsored.

In the administration: Yesterday, the FDA approved Lucemyra, the first non-opioid product to treat the symptoms of opioid withdrawal.

In the courts: Earlier this week, attorneys general in six states — Florida, Nevada, North Carolina, North Dakota, Tennessee and Texas — filed new lawsuits against Purdue Pharma, the manufacturer of OxyContin.

  • The suits were all filed in state courts, per USA Today, making them separate from the federal claims that have been consolidated before a judge in Cleveland.
  • Also this week, documents were unsealed that reveal the federal government is participating in a lawsuit against Insys over the way it marketed opioids. Bloomberg Law has more.

3. Amazon’s cameo in Cigna-Express Scripts talks

Cigna and Express Scripts filed federal documents yesterday outlining the terms and background of their pending merger (amusingly under a placeholder company named Halfmoon Parent), Axios' Bob Herman reports.

The highlights:

  • Cue the sad trombone. After Cigna’s deal with Anthem went down in flames, no other company had an interest in acquiring Cigna.
  • Express Scripts board members met in December to discuss a merger plan initiated by Cigna. During that meeting, they talked about “the potential entry into the health care industry of significant new participants” — a clear nod to Amazon.
  • Anthem’s decision to split ways with Express Scripts also factored into the pharmacy benefit manager’s acceptance of Cigna’s offer.
  • If federal antitrust regulators reject the merger, Cigna will have to pay Express Scripts $2.1 billion (Express Scripts originally wanted a $3.25 billion termination fee).

4. The biggest ethical issues for AI in medicine

Before you get too excited about those artificial intelligence doctors we’ll all have someday, you should read this briefing note from the Nuffield Council on Bioethics, a London-based group that ponders the tough ethical questions about medicine.

What they're saying: The Council has a pretty handy guide to the things that can go wrong with AI. Some of their points:

  • It’s not always reliable. (In one clinical trial, an app incorrectly told doctors to send home patients with asthma.)
  • It can’t always explain its decisions, as Axios’ Ina Fried wrote about here.
  • It can be biased, if there are biases in the data used to train them.
  • Patients could get isolated if they’re dealing with AI all the time instead of people.
  • It will have to be super strict about data privacy and security.
  • It could be used for bad things, like surveillance.

The bottom line: It’s clearly meant to be a glass-half-empty look at AI, but the point is that we should all think it through a bit and not just embrace AI because it’s cool.

5. U.S. fertility rate hits a 40-year low

Data: 1960-2016 – World Bank World Development Indicators, 2017 provisional – CDC National Center for Health Statistics; Chart: Harry Stevens/Axios
Data: 1960-2016 – World Bank World Development Indicators, 2017 provisional – CDC National Center for Health Statistics; Chart: Harry Stevens/Axios

The U.S. total fertility rate hit its lowest point in four decades in 2017, according to the Center for Disease Control, and birth rates declined for almost all women younger than 40.

Highlights from the CDC report, via Axios' Haley Britzkey:

  • The fertility rate between 2016–2017 shows the biggest one-year decline since 2010.
  • Birth rates for teenagers between 15 and 19 years old all dropped, while increasing for women in their early 40s.
  • The provisional number of births in the U.S. fell 2% between 2016–2017, sitting at 3,853,472 births.
  • Births from Hispanic women dropped 2%, and 3% for non-Hispanic white women. The number was "essentially unchanged" for non-Hispanic black women.

What we're watching today: Energy and Commerce markup at 10am. House oversight committee hearing on the Office of National Drug Control Policy (10:30am; details).

What are you watching? I always welcome your tips and suggestions: [email protected].