The Florida Roundup - Medicare drug pricing; Educators navigate new state rules 

Episode Date: September 15, 2023

This week on The Florida Roundup we discussed money and medicine, a big change is coming for Medicare and prescription drugs. For the first time, the government health system will negotiate the prices of 10 common medicines. We speak with the CMS' Director of Medicare (03:45) and the VP Pharmacy for CareMax (13:08) as well as a professor of health management (21:50). Plus, we take a look at the latest in education news (38:00) and hear about how a Florida woman and her granddaughter made history this month – six decades apart (48:08).

Today on the Florida Roundup. Our priority is to come to an agreement on a fair price for these drugs. For the first time, Medicare will negotiate prices for prescription medicine, drugs for blood clots. Diabetes and heart disease are among the first. How much money do you spend on your medicine? and heart disease are among the first. How much money do you spend on your medicine? Email us now radio at thefloridaroundup.org or call 305-995-1800. And then, I'm Iris. This is the first meeting of the Band Books Club. How some are responding to changes to what can be taught in classrooms. I'm Tom Hudson in Miami.

What you're talking about across the state this week is next here on the Florida Roundup. This is the Florida Roundup. I'm Tom Hudson. Thanks for listening this week. Eloquus, Jardiance, Xerlito. No, this is not some foreign language. This is the language of prescription drugs. Eloquus and Xerlito help prevent blood clots.

Jardiance is for type 2 diabetes. So is Genuvia and Farziga. Patients spend billions of dollars on these medicines each year, and one of the biggest buyers, Medicare, is now going to negotiate the price that it will pay. Medicare is the health insurance plan from the federal government for people 65 years old and older. It never was allowed to negotiate drug prices directly with drug makers until now. The Inflation Reduction Act, the IRA, opened the way and Medicare will soon be bargaining over drug prices for the first 10 medicines covered by the government insurance plan. Drugs like Entresto for heart failure and Enbril for arthritis.

Now, if you recognize any of these names, how much do you pay? If you or someone you know is on Medicare for their health insurance, what do you spend on prescription drugs? Email us now your story, radio at the5-995-1800. 305-995-1800. Your calls and emails are coming up. We're finally getting Medicare the power to negotiate drug prices. We've been trying to do this for years. This is President Joe Biden during a visit to Tampa in February.

Big Pharma up to now has always stopped their ability to negotiate with them. Well, they're the only, by the way, the only group in the world we can't negotiate with, wouldn't could negotiate with. But we finally got it done. Bringing down prescription drug costs doesn't just save seniors money. It will cut the federal budget by hundreds of billions of dollars. Not a joke. The Congressional Budget Office estimates that negotiating these prices will reduce the federal deficit by $25 billion in 2031.

Jean Birkin is a volunteer counselor in Polk County. She works with a program that offers guidance to seniors and caregivers on their Medicare coverage. And she says many people call looking for ways to pay for those prescription drugs. On a given day, I might have seven calls, and probably two to three of them are going to have something to do with prescription medications. The first price offers from the makers of these first 10 drugs subject to negotiation are due to the federal government in less than one month. Dr. Meena Seshamani will see them. She is the director of Medicare. We spoke with her over Zoom and then switched to a phone after some technical difficulties. Doctor, welcome to the

program and thanks for your time. What is the goal of negotiating the price of these drugs? The goal of negotiating the price of some of the highest cost and commonly used drugs by people in Medicare is so that we can get a fair price for the people who rely on these medications for their health and livelihood and for the Medicare program and the American taxpayer. Is one of the goals an actual drop in that price compared to what Medicare and patients are paying today or slowing down price increases? Absolutely. Being able to negotiate is going to improve the sustainability of the program so that we can make sure that we are paying commensurate to how these drugs impact the lives of patients. You know, one of the key pieces in negotiating is looking at the clinical benefit that these drugs provide to people and being able to see what that means in the real world.

So how will Medicare assess offers that will come in from drug makers? Those offers are due by October 2nd. That is the date that we will get data from manufacturers and also from the general public on how these drugs work, what's the cost of producing them, things like that. Just let me interrupt for one moment. How they work is not a mystery, right? I mean, these drugs have been out in the market at least seven years or 11 years. Their efficacy is not debatable, right? I mean, these drugs have been out in the market at least seven years or 11 years.

Their efficacy is not debatable at this point. It's really more about the cost to manufacture, the cost to distribute, cost to deliver, and then what the pharmaceutical companies presume would be a fair margin, a fair profit margin. You're raising a good point that I should clarify. When I said how they work, how do they benefit people in relation to what might be an alternative that somebody could take? So that's one of the things that we're looking at. We want to identify,

okay, there is this drug that's being negotiated. What are other options that are available to people? And how does this drug compare with those so that we can see what could be a fair price for this? And the comparison is on a medical side as opposed to an economic side or both? Correct. The therapeutic alternative. And with that, Tom, it's also possible that there is not an alternative, right? Like one of the things that we also want to look at is this drug addressing a currently unmet clinical need. Is this drug addressing issues for specific populations, right? So that we can make sure that we're looking at how are these drugs really improving health

and well-being for people? And having that be a cornerstone as we then also incorporate, like you mentioned, information around cost of production and distribution and all of those things to come up with an initial offer that then engages us in a back and forth negotiation process with manufacturers. Yeah. How will success in the negotiation be measured? Our priority is to come to an agreement on a fair price for these drugs.

We have this historic opportunity to drive a conversation around drugs in our country and the benefits that they can provide, how they can improve care, and how we can spend money in a smart way towards that. And a shared goal, a common theme for everyone has been improving access and affordability for the innovative treatments that people need. And with that in mind, I think there's a lot of common ground that we can leverage in our negotiation process to really drive towards what we're talking about, Tom. How do these drugs improve the health of people and how can that be reflected in a fair price? The negotiated price, assuming that there is an agreement at the end of the negotiation process, would take effect beginning in 2025. When, doctor, do you think that Medicare enrollees

would see an impact in their pocketbooks? I want to emphasize something you said, if an agreement is reached, because this is a voluntary process, right? On October 1st, manufacturers have a decision. They have to decide if they want to sign an agreement to enter into a negotiation process with us. And it is a negotiation process where you can reach an agreement. If they do enter into the negotiation, are they required to come to a negotiated settlement? Are they required to come to a negotiated settlement? No. What happens is if they decide that they want to negotiate with us, if an agreement is not reached, then they have options. Centers for Medicare and Medicaid Services could face taxes up to 95% of sales on their drug doctor or stop selling drugs to Medicare and Medicaid. How do you expect those potential penalties

to affect negotiations? I think those are decisions that manufacturers will have to weigh as they are working with us as part of a negotiation process. There are always, as they are working with us as part of a negotiation process. There are always, in any negotiation, there are factors that each side must consider as they are approaching negotiation. On the access question, Doctor, will drug makers be banned from requiring prior authorization to the medicines after coming to a negotiated price, for instance, with Medicare? One of the things that we put in our guidance on the negotiation process is that we want to ensure meaningful access to the drugs that have an agreed upon negotiated price. As part of our normal formulary review for the Part C prescription drug program in Medicare, we are always looking at

making sure that these formularies are not discriminatory and that they are following well-established clinical guidelines. We will be using that process here as well, where we expect plans to provide justification if a negotiated drug is not on a preferred tier, if there is utilization management being utilized. We will be reviewing those justifications and using our formulary review process, again, with an eye toward the goal of making sure that the formulary is not discriminatory and that it is clinically appropriate and sound. How will any of the savings that may be realized in a successful negotiation be passed along to Medicare patients? Ultimately, this is enabling us to get a

fair price for everyone, where we are driving a conversation about what it is that matters to people in the drugs that they take for their health. Being able to drive the price conversations in that way, along with all of the other provisions in the Inflation Reduction Act, like the $2,000 out-of-pocket cap that's going to go into effect in 2025, getting vaccines at no cost sharing, insulin having a $35 cap on a month's supply that people will pay. All of that together is really game-changing and life-changing for people in the Medicare program. Doctor, thanks so much for your time today. Much appreciated. Thank you again for having me.

Dr. Meena Seshamani is the Director of Medicare. So what do you think about Medicare negotiating drug prices for the first time? If you're on Medicare, what do your medicines cost you? Radio at thefloridaroundup.org is our email. Write us a quick note, radio at thefloridaroundup.org is our email write us a quick note radio at the floridaroundup.org or call 305-995-1800 305-995-1800 you may have to wait just a bit but it will be shorter than waiting for a doctor's appointment i can assure you now florida has more people on medicare than any other state except one and almost almost one in four people calling Florida home

rely on the federal government for health insurance. So this is a big deal. Medicare can be the alphabet soup, though, of plans. Part A is hospital insurance. Part B is like traditional medical insurance for doctor visits and outpatient care. Part D is for prescription medicine. Now, part C is what's called Medicare Advantage. These are insurance plans from Medicare-approved private insurance companies. They put a cap on your out-of-pocket expenses, and they may offer extra benefits that regular Medicare doesn't. A little more than half of Floridians on Medicare have a Medicare Advantage plan. Tens of thousands of those are with CareMax. Brian Brito is the vice president of pharmacy for CareMax.

Brian, welcome to the program. Thanks for your time. Does CareMax support these Medicare price negotiations for prescription drugs? Absolutely. We're thrilled. We think this is a landmark undertaking by the administration, and we're excited that it's going to have a positive impact on our members and ultimately in healthcare in general here in the United States. What could be the impact, though, of a negotiated

maximum fair price, is what the law calls calls a maximum fair price for these first 10 drugs that have been identified as targets of the negotiations? Creating some transparency. You know, a lot of these products, there's no visibility into what the actual cost is to the health plan because there's these rebates that have been kind of kept confidential and close to vest for a lot of times. So once the price is negotiated, Medicare will have a pretty clear understanding of what the price is actually going to be at the end of the day of the health plan. For members, obviously, there's a reduction in the overall spend, which should lead to lower premiums, lower co-pays potentially, moving some of those savings to other areas, particularly premiums and taxpayers.

Do you really think that this negotiation over prescription drugs, 10 of them, could lead to lower insurance premiums for Medicare Advantage patients in Florida? I do. I mean, those 10 drugs accounted for close to $50 billion last year. How much does CareMax and its patients pay for those 10 drugs? Any idea? That's a great question. I know those are very common drugs for our members. I would venture to say that it would be very similar, close to 10 to 20% of our drug spend would be on those products. Absolutely. Will CareMax pass through any or all of the price changes to its Medicare Advantage patients should there be

successful negotiations of lower prices for these medicines? Absolutely. I mean, you know, our goal is to provide the lowest cost at the best healthcare. So if those costs are reduced, we would absolutely pass those along through our negotiated contracts with our Valley-based care plans. You know, a lot of these products are the drivers of members going into the catastrophic phase. And unfortunately, a lot of them decide to go without the medication and that's not what anybody wants, right? You know, that can lead to hospitalizations and complications with their health. And so, you know, by reducing the costs and limiting the catastrophic amount to

$2,000, we're thrilled. We feel like there's going to be a lot of medications that, you know, with these barriers removed, they're going to stay on their treatment and keep them healthier and out of the hospital. So we're thrilled. Do you think it increases the volume, then the demand side for these medicines if price cuts are actually realized? The organic demand will remain the same. I think maybe perhaps the utilization may go up, but I think ultimately that's what we want, right? The adherence of members taking these medications is what we want, right? That's the key component in treatment, any treatment plan. And then with a reduced cost, the total spend will still be less, ultimately,

I mean, theoretically, than what it is today. So I still think it's a win-win. You know, what is the realized savings going to be? We're not sure yet because those price negotiations haven't been completed. But we're hopeful that, you know, a couple of the key components in this bill are going to really help drive healthier patients. What do you think the impact of Medicare price negotiations over these medicines will be on the private insurance market? Yeah, I do think that there will be a trickle down effect. I mean, they're not going to just negotiate these prices for Medicare

Advantage plans. It'll likely be a negotiation that'll carry over across the commercial and ACA plans. And so we think there will be a positive impact as well. One of the other things that I think is important is Florida recently passed the Drug Transparency Act. Yeah, I was just going to ask you about the prescription reform law that was recently passed and enacted. It targets pharmacy benefits managers and drug makers, does a number of different things. It requires drug makers to disclose price hikes of 15% in a year. It bans pharmacy benefit managers from requiring patients to use step therapy to, in other words, use lower cost medicine, for instance, first. It also bans those pharmacy benefits managers to steer patients to a mail order pharmacy that they own.

It's only been a couple of months that this law has been in effect. Has the pharmacy business that you oversee at CareMax seen an impact in the few months of this law? Not yet, but we're expecting the impact to start now on January. Part of the provision was allowing the renewal of some of our agreements with some of these PBMs and plans. And so that'll likely happen on January 1st. And we'll start to see, we'll likely get more access. And hopefully some of those rebates will be passed on back to the health plan and back to either CareMax groups or groups like CareMax and reducing premiums. I mean, that's ultimately the goal. And we'll have access to be able to support more of our members without that mandatory requirement

of using a PBM-owned pharmacy. So we're excited about it. And hopefully now starting in 2024, we'll start seeing all of the benefits. I just want to ask you again, like slowing the rate of increase in healthcare and health insurance premiums is one thing, but actually lowering the absolute cost of premiums

is something altogether different that, you know, I don't know if you've seen it in your career. I don't think I've ever seen a health insurance premium year over year with the same company, the same coverage actually go down. It's usually if it goes down, perhaps coverage goes down. That's exactly right. Not without a subsidy or, or, or some sort of somebody's paying it. Yeah, that's right. Yeah. Yeah. It could be an employer. It could be the federal government in some cases. Agreed. I mean, that's where that's where I think folks need to temper expectations. Let's see where these price negotiations end up.

And let's see how that trickles into, you know, a reduction in premiums. You know, fingers crossed we can accomplish that goal through, you know, not only this first 10 drugs, but also the subsequent 10 and 15 in the following years. Brian Brito is the VP of Pharmacy for CareMax. Brian, thanks so much for your time. Absolutely. It was a pleasure. Thank you, Tom. Still to come in our program, the fight drug makers are putting up over prices and your stories of medicine and money. Radio at thefloridaroundup.org or call 305-995-1800. You're listening to The Florida Roundup from your Florida public radio station.

Welcome back to The Florida Roundup. I'm Tom Hudson. Thanks again for listening this week. Today, we're talking about money and medicine. One in four Floridians is on Medicare. Maybe it's your mom and dad. Maybe it's your great aunt, your neighbor. Maybe it's you. Well, next month, Medicare will start negotiating with a few pharmaceutical companies over the price of 10 commonly prescribed drugs.

These are like blood thinners and diabetes drugs, among others. Next week on this program, we're going to be talking about the child care cliff. Have you heard about this? Well, federal government money that was directed to child care centers is due to run out at the end of this month. More than 200,000 Florida children could be affected as child care operators may be forced to scale back. And the lack of child care costs the state economy billions of dollars, according to a new study, as parents wrestle with finding affordable and quality child care or missing work. Now, those are the big statistics around child care, but they don't really tell your story, do they? If you're a working parent

or caregiver, how are you balancing work and child care? Maybe you're a grandparent who helps out. So what's your story of working and caring for your kids? Email us that story, radio at thefloridaroundup.org, radio at thefloridaroundup.org, and maybe we'll use your story next week. Today we're talking about your medicine cabinet and your pocketbook, the cost of prescription drugs. It's an issue that cuts across the political divide, but how to address it hasn't been. If you rely on prescription drugs, you know the bite they can take out of your budget.

One of the biggest buyers, Medicare, will begin negotiating prices for the first time starting next month. So what does your medicine cost you? How does the price of prescription drugs affect that pocketbook? Call us now, 305-995- Call us now 305-995-1800 305-995-1800. Emma Dean is with us. She's a health management professor at the University of Miami Herbert Business School. Great to have you here. Professor, let's talk first about what do you make of this list of the drugs that they've identified to be the first to be negotiated by one of the largest buyers in health care, which is the federal government. Yeah, this list is exactly

what we would have expected given the design of the legislation. These are expensive drugs. These are high spend drugs, meaning a lot of people take them. Additionally, these drugs have been on the market for, you know, depending on the type of drug, either at least seven years or 11 years, which means by the time they're price controlled, it'll be nine to 13 years. So they have had a decent amount of patent life where they've been able to sell to people without price negotiation. So what do we know now about the prices that Medicare is paying and patients are paying for these medicines?

So these are, again, a list of relatively high-cost drugs. So giving you an example, I think, of Eliquis, which is one of the commonly taken drugs, I think out-of-pocket it's around $600 a month if you do not have insurance. Even with insurance, we're talking about co-pays that could reasonably be $100 a month. Now, this isn't oftentimes the only drug people are taking.

And this is, again, for people who have insurance. So some of these drugs can be very high, again, for people who have insurance. So some of these drugs can be very high cost, even for the insured. And so does that give Medicare leverage in negotiating these prices? If that's the starting price, which seems awfully high. And for anybody taking that medicine, the balance between, well, blood thinner, fighting blood clots at maybe $100 or more per month, or the health realities that it could face if you don't take the medicine. So Medicare is going to have a lot of leverage just because they are a large insurer of people.

And so right now, what we have is individual Medicare or Medicare Part D plans, essentially, or Medicare Advantage negotiating. They're going to have less individual market power than Medicare. So Medicare as a whole, because of they're such a large provider, will have more leverage. The other thing, though, they have said in Medicare how they're going to negotiate those prices. They're going to allow for drugs that have additional benefits that truly bring a lot to patients. They're going to pay more for those drugs. Now, if you're a drug where there are multiple lower-cost competitors, that might be a place where they're going to say,

well, we have these lower-class alternatives, so we're going to negotiate or at least put our starting price lower. So all in all, will a Medicare patient see any drug savings? Perhaps there may be parts of their medicine cabinet that are cheaper beginning in 2026, but other parts that are more expensive that aren't covered by these negotiations. Right. I mean, in theory, that would be kind of a trade-off on the part of the insurers then saying, well, if you're going to cut my price here, I'm going to try to raise my price elsewhere. Whether they have the leverage to do that is unclear. Insurance companies still do have power to negotiate those other drugs. Indeed, they do. Emma Dean is with us, a professor at the University of Miami Business School,

focused on health management, talking about Medicare, prescription drug negotiation, and your money, 305-995-1800. 305-995-1800. Stu has been listening in from Lake Worth. Stu, you're on the radio. Thanks for calling. Hello. I was a negotiator more than 20 years ago,

an international negotiator for pharmaceutical companies. And I had lunch one day with a pharmaceutical, American pharmaceutical representative who said to me that they negotiated their prices in every country but the U.S. They can't afford to do it here because the U.S. is a cash cow. Emma, you're nodding your head yes to Stu's experience there at lunch a few years ago. Stu, thanks for sharing that experience. Many of the companies have pushed back. All these companies have pushed back. They've filed lawsuits. They've made arguments

and are making arguments that any negotiation with Medicare is likely to cost them money that they plow back into research and development for new medicines. Yeah, absolutely. And so the U.S. is about exactly what you were saying, the cash cow. It's about 40 percent of the global pharmaceutical market if you talk in terms of sales. So anything that happens here is going to have a big effect on overall profits. On the innovation piece, yes, there's been a lot of research that shows that as you pay more, we see more innovation. You can't completely discount that fact. However, a lot of this, some of the newer research has shown that some of this additional innovation is more incremental versus completely innovative. And so one thing that the Inflation Reduction Act says is that

you need to have been on the market for, again, at least nine or 13 years, depending on type of drug. So we are allowing, and we do want to continue to encourage innovation. So they're allowing drug companies to charge higher prices in that window to allow them to recoup the high cost of R&D and also encourage future innovation. They have said that the CBO has estimated this will lead to 13 fewer drugs launched, but that's from a pretty high starting point of, I think it was like over 1,000. Now, that being said, we don't know how important those 13 drugs would be. We can't say that.

They might have just been incremental. It could be orphan drugs, so relatively small populations. But for any one of those patients that may have benefited, it could mean life or death. You never know. And so you can't completely get rid of this innovation argument. They have built in things to try to mitigate it. Well, and isn't the market also the demand for a significant driver of innovation? Absolutely.

So if we have a completely innovative drug that patients want, insurance companies are going to want to cover it even without regulation. 305-995-1800, Medicare, prescription drugs, your money, your medicine cabinet and pocketbook. In Trinity, Neil has been listening in. Go ahead, Neil. You are on the radio. I have been prescribed Eloquist by my cardiologist

because I have had two valves replaced in my heart and I've had the heart arteries replaced as well. And the cost for Eloquist through my Part D plan is more than $500 per month. Oh, my gosh. And I talked to my cardiologist, and he gave me a list of Canadian pharmacies that I could check out on their website, and I found one that I can get the Eloquus for a 90-day supply for $72, delivered right to my home from India, where in India is one of the countries that manufactures a lot of the drugs that the pharmacies dispense in this country.

Yeah. Neil, let me just work through those economics that you're weighing here, just so that we're clear. On one hand, you could get this prescribed drug here in the United States for 90 days for about $1,500. Is that about right? Yeah, that's about right, yeah. Or you could buy this through a Canadian pharmacy for $72 for 90 days. That's correct. So what are you going to decide to do? Oh, I've already done it. I've been getting it decide to do? Oh, I've already done it. I've been getting it. I've been getting it for the last six months from India. Neil, thanks for listening and calling in and sharing that story. Neil Entredity there has opted to re-import his drugs through a Canadian pharmacy. And Emma, one of the pushbacks that the pharmaceutical industry and those that are not supportive of Medicare negotiating drug prices said,

you know, folks like Neil may be putting their health at risk by not knowing that, not knowing exactly quality control and the kinds of drugs as they're perhaps reimporting them, but at a much lower price. But making that economic choice, $1,500 every quarter or less than $100 every quarter. I mean, it's a completely understandable economic trade-off that people have to make. And I think his point is really getting to, we do need to encourage innovation, but does the U.S. have to be the one paying for all that innovation? And right now, we're the non-negotiators, though.

Doug sent us an email, radio at thefloridaroundup.org. Doug is listening in in Hollywood. He says that he's over 65. He's on Medicare with a Medicare drug plan. He has been taking Entresto, I think one of the heart medicines that's on this list to be negotiated. He says it costs $180 a month.

In total, Doug writes, I spend close to $600 a month on drugs, even though I pay $65 a month for an insurance plan. And I think his point is an important one. We think about these drugs as individual drugs. People often take multiple drugs, especially if you're a Medicare patient. You might have multiple chronic conditions or a chronic condition that requires multiple drugs. You add these things up, this can be really expensive for people over time. And we do push a lot of these costs to patients. How do drugs affect the cost of health

care? So if you look at our health care spending, it depends on how you define it. They're about 10% to almost 20% of our spending, depending on which drugs you include. So for instance, physician administered drugs are about 40% of our total spend, but they're not the biggest driver. Actually, it's hospital expenditures. And then how do, just sticking with prescription drugs, how do drug prices affect the price of insurance? Oh, absolutely. So just having, even if you're not taking one of these drugs, you might see your premiums decline. That's the $45 he's paying a month for insurance. Yeah, $65 for Doug. Or $65 for Doug. Apologies.

Yeah. So even if you're not taking one of these drugs, this is going to change the overall cost across the whole system. Those should be passed on, in theory, to consumers in the form of lower premiums. And so as it gets down to Medicare negotiating these drug prices, you heard it in our previous interview with the head of pharmacy at CareMax, one of the Medicare Advantage providers here in Florida, thinking that this could lead to an actual drop in health insurance premiums. I'll be honest with you, Emma, I'm very suspicious about that, right?

It's a little bit, I mean, insurance prices, particularly in Florida, for just about anything really don't go down, regardless of what kind of reforms may be put into the market. And I think this was got to one of the questions you asked earlier, how are these savings going to then make their way into patients' pockets? And in theory, if the insurance companies are competitive, we should see them passing on the savings in the form of lower premiums. If we don't have a competitive insurance market, we could see the additional profits in theory. Yeah. And are we to assume that the Florida market is so attractive to insurance companies because of the demographics, the size of that market, that they won't just go elsewhere? Yeah. And South Florida in particular is a very competitive

Medicare Advantage market. But yes, the state of Florida, because we have a lot of elderly people who are on Medicare, is a very, very lucrative market. Yeah. We're speaking about Medicare and drug negotiations that are due to begin in less than a month. Emma Dean is with us, health management professor at the University of Miami Herbert Business School. We want to hear from you, 305-995-1800, 305-995-1800, as you are listening to the Florida Roundup from your Florida Public Radio station. Amy O'Rourke works with seniors and caregivers in the Orlando area, and she's the author of a book entitled The Fragile Years. We asked her about the impact of

drug prices and the difficulty for Medicare patients. The other important thing to think about is the medication companies have coupons or deals. Well, Medicare recipients can't take advantage of those coupons and those deals because any company that's working with Medicare can't charge differently for other customers. So Emma, explain that here. There's coupons in the marketplace. Folks may see the advertising, for instance, either at the pharmacy or on TV or in magazines. But yet, if you're a Medicare patient, you may not be able to take advantage of those coupons.

Right. And the reason these coupons are in place is because manufacturers like coupons. They like them because what insurance companies do to lower costs is to encourage a patient to switch to a cheaper alternative. They'll put the cheaper alternative at a better tier with lower cost sharing. So these coupons then can make the consumer less price sensitive. This is why manufacturers like them, right? Because then you're more likely to take their more expensive drug as opposed to a cheaper

competitor. Because the U.S. healthcare system knows this, Medicare said, you cannot use these coupons. We know what they're used for. And so they do not allow Medicare patients to use them. They're not the only program. The whole state of Massachusetts also does not allow copay coupons. But that is the reasoning behind it. As a patient, however, if you're a Medicare patient, well, this seems extremely unfair, right? I don't get the benefits of these coupons that are trying to improve access. Yeah. So no coupons, but thinking about Canada instead for sources.

Or an Indian on pharmacy. Exactly. Andrew has been listening in from Boca Raton. Andrew, go ahead. You're on the radio. Thanks for calling. Oh, great. Yeah. Thank you very much. I've lived in Canada 40 years, lived in the United States for 10 years, and I think that the counterarguments that pharmacies use, that there's potential quality issues with Canadian drug manufacturers, that's ridiculous because drug manufacturers actually, in the United States, import from Canada. So it's the fourth largest import after China, Mexico, and India.

So they're importing products from Canada themselves, putting it in their drugs, into their drugs. So it's like a ridiculous straw man argument they're simply using to preserve their, what I think is like ludicrously high profit margins in the United States. Andrew, thanks for sharing that perspective. I think maybe former Canadian in Nabokuro-Tone listening in here to the Florida Roundup. He's talking about quality issues, talking about reimportation. We mentioned earlier the age of some of these drugs. They've been in the market for a good long time. Some of these companies have made hundreds of millions, if not more, in profits from these.

Nobody's here to argue against that per se, but what about the patent issue and the generic competition that helps drive some of the price of some of these medicines lower? Yeah. So we do want to encourage innovation by allowing some effective patent life. The issue with some of the drugs that are on this list, Embril is a case note example here, right? So they- This is an arthritis medicine, I think, right?

Yes. It's an anti-TNF. It's for autoimmune diseases, primarily rheumatoid arthritis and some others. And so this is actually launched in the US in 1999. And it won't get a generic competitor until 2029, I believe. So this is a very, very long time. So what Embril has done is their first patent expired in 2012. Okay. Yeah. So their initial patent. So what they'veil has done is their first patent expired in 2012. Okay. Yeah. So their initial patent. So what they've done is they've actually added additional patents. We call this thickening. And so what they've done is like patented minor things about the drug, maybe a

color change or something like that. That's actually extended their effective patent life. And it's actually prevented then generic competition or biosimilar competition in the case of Embril. Just 30 seconds here but how could so this Medicare negotiation has nothing to do with patent reform. Is there a role for patent reform here with drug prices? Yeah and a lot of people say well we shouldn't be price controlling that's not as effective once you have generics in the market that's really competitive that drives down prices without any government intervention just markets working as they should and that would actually play a role for having patent reform

so we make sure that we do get generics into the market. We don't allow these small tweaks that allow drugs to extend their effective patent life. Emma Dean has been with us, the health management professor at the University of Miami Herbert Business School. Emma, thanks so much for sharing your expertise with us. Thank you. Appreciate it. Still to come on our program, a new college admissions test in Florida. You are

listening to the Florida Roundup from your Florida Public Radio station. Stick around. This is the Florida Roundup. I'm Tom Hudson. Thanks for listening this week. We're several weeks into another school year here, one that began with some uncertainty around how new state policies would impact learning from kindergarten to college. There's plenty of controversy around new rules over school curriculum and a wave of books being removed from school libraries. That's something the American Library Association called unprecedented earlier this year. But one of the consequences of banning books is that it makes some curious and want to read them. From our partner station, WLRN in Miami, Kate Payne reports.

I'm Iris. This is the first meeting of the Banned Books Club. On a rainy afternoon at Books and Books in Coral Gables, eight people pulled up some chairs in a corner by the cafe. For now, I just want to start with reading books and discussing why they're banned and, you know, what we think of that, which for me, I know, you know, I don't like censorship, so. This is Iris Mogul, the founder of the club. She's 16 and a junior at the Academy for Advanced Academics. Some of the people who showed up were pleasantly shocked by how young she is. So I have a little activity planned in this little baseball cap. There's some book covers and then book title, author of like very frequently famous fan books.

They took turns pulling the slips of paper out of the hat and then passed it on. I'll start. Here we go. One flew over the cuckoo's nest. I feel like that's like on all the lists I read of banned books. There is 1984, The Handmaid's Tale, Harry Potter, books that have been challenged in schools across the country. Policymakers, especially in Florida, have been taking steps to limit access to books about controversial topics like race or sexual orientation. Iris says she wanted a place to dig into James Baldwin and Toni Morrison.

I didn't know a lot of people my age that read for pleasure. a lot of people my age that read for pleasure and I wanted a space to discuss everything, all the thoughts and things I was learning from these books. Some of Iris's friends came out to support her. Gia Cabrera is in the 12th grade at Coral Gable Senior High. In a way, Iris says Gia helped make this book club possible. Like, you got me back into reading. Because you were always, like, talking about, like, how you were reading, and I was like, wow, she has her life together, like, whatever. And then I was like, I'm going to start reading. That is what happened.

I always thought reading was lame, and then I looked up to you, and I saw you reading, and then I was like, wow, I can be cool and read? This was inspiring me. I'm so proud of you for doing this. Like this takes work. I can't believe you think it's lame though. No I thought it was lame. The club's main task for the night was to decide on a first book. Iris threw out some options. And then Shriek Heart Named Desire, Running With Scissors, the memoir Augustine Burroughs, Their Eyes Were Watching Gods, classic. Ultimately, they settled on Their Eyes Were Watching God by Zora Neale Hurston. The Florida writer died in obscurity, but is now recognized as a signature voice of the Harlem Renaissance.

Awesome, I'm excited. All of them are on my reading list, but can't go wrong. But the conversation didn't go wrong. But the conversation didn't stop there. No one seemed to want to leave. So they did what readers do. They talked about what's on their nightstand. I'm reading When We Make It. That's Tanya Malave. It's about this girl, New York girl growing up in Brooklyn. I'm from New York, so I grabbed two. Oh, really? Yeah. I would love to go back. I miss New York, but my husband loves Miami, so here's home.

And now we have a bug fight. And now we have a bug fight. Now you have ties. I'm Kate Payne in Coral Gables. New social studies teaching standards in Florida public schools have taken aim at Black history, including a standard that some Black people benefited from skills they gained while enslaved. Now that followed the banning of AP African American history here in Florida, and both have faced sharp criticism by teachers and civil rights groups.

The regulations do not affect private schools, and some are offering educational experiences rich in civil rights history. Danielle Pryor reports from our partner station in Orlando, WMFE. In her classroom at Monarch Learning Academy in Orlando, Marsha Hall is surrounded by images and quotes of civil rights icons as she plans a trip with 14 of her 7th grade students to Alabama. They're going to see some of the most important sites of the civil rights movement of the 1960s, like the Edmund Pettus Bridge, where thousands of people marched for equal voting

rights despite the threat of police violence. And so they're able to see if we're driving it, they're able to get, again, context for having had a walk, right, for that kind of distance and what it takes for people to decide that that is so important that they're going to do it. They'll also visit the Rosa Parks Museum and the National Memorial for Peace and Justice that commemorates Black victims of lynching. Parents and students must agree to go on the trip before enrolling in the course, one that Hall aims to provide context to the country's history in its fullness. Right, children need to be taught the truth and again, to the country's history in its fullness.

Children need to be taught the truth, and again, age appropriately, let me say that, age appropriately and with context and with the opportunity to disagree, with the opportunity to feel upset and work through those feelings. Hall can plan a field trip like this without fear of losing her job because her school is private, unlike public schools which are held to new social studies standards this year. Florida public school kids won't be able to take AP African American History, and discussions around race are limited by the Stop Woke Act. The Department of Education has defended these new standards, saying they're, quote, comprehensive and that AP African American History contains age-inappropriate materials. Rollins College professor Eric

Small thinks it's a great idea that some teachers and students are pushing back, especially those with the ability like private institutions. But he's concerned for public school kids that won't have these same opportunities. If we inadvertently or intentionally make the mistake of telling them that some of the most egregious and immoral acts that we participated in had good outcomes, then they might see those acts as less egregious, less immoral. Smoss says in the age of the internet and social media, ignorance can easily be weaponized. And those young people who might have been miseducated might find themselves in a chat room with those who have bad intentions for them,

who might radicalize them and then coerce them into joining a white supremacist group or a terrorist group. Back at Marnark Learning Academy, Hall says she wants her students to have the tough conversations and to feel the tough emotions now while they're still in a safe space of a classroom. Otherwise, she says they'll be woefully unprepared for the real world. That's why we do it in class and we're not just sending them out into the world with information for them to try and make sense of something that even some grown-ups can't make sense of. Marguerite McNeil, who is Hall's principal and the director of the K-8 school, is proud of Hall and her students and says it was an easy

decision approving the field trip. I don't know what the fear of knowledge, I don't understand fear of knowledge. I have more of a fear of lack of knowledge. But Florida isn't the only state that's limiting what kids can learn. Last month, Arkansas followed suit and won't allow its public school students to take AP African American History for credit either. In Orlando, I'm Danielle Pryor. Education changes and controversies have also included Florida's public colleges and universities. The latest is this month's decision to okay a new college admissions test. Florida is now the first state university system to accept the classic learning test, also called the CLT, for students applying for college. From our partner station WUSF in Tampa, Nancy Guan has more. The classic learning test was developed in 2015 and is modeled after a classical education curriculum. About a dozen small private institutions in the state already accept the CLT.

Now, Florida is the first to use the test in its statewide public university system. Supporters say this gives students an alternative to the SAT and ACT exams. But critics, including United Faculty of Florida President Andrew Gothard, questioned the CLT's reliability. No one who's actually in higher education was asking for yet another test that students could use to get into colleges and universities. This is entirely politically motivated. Gothard says the state should invest instead in diversity programs and other pathways for college applicants. Nancy Guan, WUSF News. Next week on this program, we're going to be talking about kids again, kids in child care. Finding affordable and high quality child

care is tough in the best of times. Federal government grants to child care operators to help them stay open and staffed is due to run out at the end of this month and some may have to reduce hours or cut the number of kids they can take so what's the impact for florida families if we don't open mom can't go to work if we're not here the parents don't have a way to find to go to their job that's emily alvarez at the creative learning center in south florida i spoke with her last year about the challenges of child care, which could get worse next month. So, mom, dad, abuela, uncle, neighbor, we want to hear your story about balancing child care and working. How do you make it all work for you and your family, or do you? Email us now, radio at thefloridaroundup.org.

Radio at thefloridaroundup.org. Radio at thefloridaroundup.org. We may share your story next week. Finally on The Roundup, 62 years ago this month, Yvonne Lee Odom made history, and last weekend, her granddaughter did too. Odom was 15 years old in 1961 when she was the first black student at a high school in Delray Beach in Palm Beach County, ending school segregation. Last week, she watched as her granddaughter became the youngest American woman in more than two decades to win the U.S. Open tennis tournament. Here's Wilkin Brutus from our partner station, WLRN. A day after the championship win, Coco Golf's grandmother,

Yvonne Lee Odom, and her family celebrated the historic win at St. John Missionary Baptist Church in Boynton Beach. In the moments after her granddaughter became one of the U.S. Open's youngest winners, Odom offered some advice. Keep going. I am so happy for her because she is a hard worker. She's been that way. My text to her simply was to enjoy the moment, then get back to work. And I always used to tell her, I said, Coco, you the it girl. So everybody want to beat you.

19-year-old Goff became the youngest American player to win since Serena Williams in 2001. Goff is ranked third in the world for women's singles and number one in doubles. I'm Wilkin Brutus in Palm Beach County. That's our program for today. The Florida Roundup is produced by WLRN Public Media in Miami and WUSF Public Media in Tampa. Bridget O'Brien produced the program. WLRN's Vice President of Radio and our program's Technical Director is Peter J. Mares. Engineering help each and every week from Doug Peterson and Charles Michaels. Richard Ives answers our phones.

Our theme music is provided by Miami jazz guitarist Aaron Leibos at AaronLeibos.com. Thanks for calling, emailing, listening, and above all, supporting public radio in Florida. I'm Tom Hudson. Have a terrific weekend. I'm Tom Hudson. Have a terrific weekend.