Oral Chemotherapy Affordability Hearing — PBMs, Insurance & Cancer Drug Costs — September 15, 2026

26:17I recognize myself for the purpose of making an opening statement. And first of all, like I said, I apologize for being a little late here. I appreciate how some of you had to come quite a distance to be here.

26:31Welcome to today's hearing of the Subcommittee on Healthcare and Financial Services. Today we're examining why cancer patients in this country are forced to pay far more for chemotherapy in a pill form than the very same class of treatment delivered through an IV.

26:48Chemotherapy is one of the oldest tools we have to fight cancer. For decades, it was delivered almost entirely through an IV in a hospital or a clinic. Medicine, however, has changed. The Food and Drug Administration has now approved more than 50 oral anti-cancer medication and it's estimated that between a quarter and a third of the cancer cancer drugs in development today will be available only as a pill.

27:15For many patients, that's a breakthrough. An oral drug can be taken at home. It less invasive less disruptive and just as effective as an IV infusion For other cancers it the treatment the doctor prefers In other words it better than an IV with an infusion For others it the only option a patient has.

27:40You would think that a less invasive at-home treatment would also be easier on the patient's wallet, right? You don't have to go to the hospital, da-da-da. Unfortunately, the opposite is true, and the reason has nothing to do with medicine.

27:53It has everything to do with how the drug is billed. When chemotherapy is delivered through an IV, it's covered under a health plan's medical benefit. The patient usually pays a modest copay and their out-of-pocket costs are capped for the year.

28:08When the exact same chemotherapy comes through as a pill, it gets thrown onto the pharmacy benefits specialty tier. In other words, a flat copay, instead of a flat copay, the patient pays coinsurance, a percentage of the drug's price, and in the commercial market that bill often has no cap at all.

28:33One in ten patients prescribed an oral cancer drug face a copay of $2,000 or more just to fill their very first prescription. Unsurprisingly, about one in ten patients never pick up their medication at all.

28:52Think about that, they got cancer, and one in 10 times I'm not even gonna pick it up. A cancer patient walks into a pharmacy holding a prescription that could save their life only to leave empty handed because they cannot afford it.

29:06So who profits from, in essence, letting these people die? The answer far too often is the middlemen, the pharmacy benefit managers or PBMs. The three largest of these companies are also owned by the nation's largest health insurers.

29:25They decide which drugs a plan will cover, the set which the patient pays, and they collect rebates calculated as a percentage of the drug's list prices. The Federal Trade Commission has found that the largest PBMs marked up specialty drugs, including oral cancer drugs, by hundreds and even thousands of percent when they were dispensed through the pharmacies these same companies own, pocketing billions of dollars in the process.

29:54In other words, a way to make more money, not to do what's best in the patients. own interest. And I think the system as a whole doesn't save any money. And when they're not marking up the price, they're delaying the care through prior authorization, through fail-first-step therapy, and forcing patients to fill their prescriptions through these same company-owned pharmacies.

30:19If you just give them the drug in the first place, save a little money, but even more save lives. And when they're not marking up the price, they're delaying the care. Forty-three states have passed laws to fix this, including my own state of Wisconsin, requiring that oral and IV chemotherapy may be treated the same.

30:41But those state laws cannot reach employer plans that cover most working Americans because federal law preempts what the state legislatures are doing. Only Congress can close that gap. That's why I personally have introduced the Cancer Drug Parity Act, which is bipartisan with a straightforward premise.

31:00A health care plan cannot charge a patient more for oral cancer than for IV treatment it's already covering. This hearing will highlight how the problem took root, how middlemen are harming patients, and what Congress has to do to improve the lives of cancer patients across the nation and increase the chance that you will live through cancer.

31:23We are honored to have expert witnesses here with us today to help examine this crucial issue. With that, I yield to you don't look like member Krista Morthy. With that, I yield to Congresswoman Randall for your opening remarks.

31:40Thank you, Chair Grofman. Appreciate finally having a hearing again in this subcommittee. it's been nine months since we've gotten together, nine months since the majority has chosen across many committees to hold bipartisan or to hold partisan roundtables instead of hearings.

32:01So it's great to be back in this room for a hearing. I'm pleased to be filling in for as the ranking member today and to discuss the ways that health care has become Unaffordable and inaccessible.

32:11Rising health care costs are constant concern for me as they are for so many millions of Americans. Daily life is increasingly unaffordable and the cost of health care is a huge driver Choosing between health care and other essentials like food rent child care is keeping Americans up at night And I know that government can help My younger sister Olivia was born with complex disabilities and because of Medicaid expansion my family was able to keep our home and afford her care and she was able to live a thriving life for 19 years.

32:42Every family should have the ability to care for their loved ones. No one should have to worry about how or even if they can afford health care. We should be working to bring down the costs and bring down health care prices and improve access to care so that quality care is available to all, including those in rural communities like mine.

33:07The cost of health care can haunt families for years, and many Americans struggle to survive the crushing weight of medical debt. Because of soaring health care costs, medical debt is an issue that disproportionately impacts people of color, women, families, and those without insurance.

33:23Addressing these disparities is absolutely vital if we are to have a health care system that is affordable, accessible, and improves outcomes for Americans, regardless of where they live or how much money they have.

33:37And the high cost of medication is a big part of the problem, including oral chemotherapy. In one recent survey, almost half of the respondents reported being underinsured for prescription medications. Even with insurance coverage, they could not afford all the medications they need.

33:54This should concern all of us. And I was so grateful to hear the chairman lay out some of the problem with oral chemo, especially. The Trump administration and my Republican colleagues, however, have only made the problem worse over these last two years.

34:13Policies that are making health care coverage more expensive have been passed by this majority, they have significantly cut funding to vital medical resources and programs across the country. The Republicans' so-called Big Beautiful Bill Act cut Medicaid, stripping millions of their health care coverage.

34:27Then Congressional Republicans refused to extend the ACA tax credits that helped people afford their insurance premiums. These unconscionable actions only led to skyrocketing health care premiums and out-of-pocket costs for families across the country.

34:43In effect, Republicans in Washington have traded your health care for tax breaks for billionaires. Under Republican leadership, up to 10 million people are estimated to have already lost their health care coverage This means an additional 10 million people struggling to see a doctor or pay for a prescription They have created an environment where yet another person and another family are forced to choose between their health or rent And that's not all.

35:12The Trump administration also canceled $160 million in funding for Washington State that was meant to support disease monitoring and vaccine programs. And these cuts also make Americans less safe and risk their health. At the same time that Congressional Republicans are making healthcare more expensive and harder to access, the Trump administration is also destroying the research and innovation we rely on to cure diseases like oral cancer, improve treatments, and advance healthcare.

35:40The administration has terminated, suspended, or otherwise disrupted thousands of grants, resulting in a loss or disruption of over $16 billion in scientific research. These cuts have caused a major disruption in our nation's scientific research engines and are costing lives.

35:59This hits particularly close to home. Cancer patients from across the Olympic Peninsula and across the country travel to receive treatment from the Fred Hutchinson Cancer Research Center in Seattle, a world-class research institution that has been affected by federal funding cuts and staff reductions.

36:16Cutting cancer research is evil, full stop. This administration has robbed our society of new treatments and cures, and cancer patients and their loved ones will suffer. Early career researchers are now choosing different research paths because of the instability that President Trump has created.

36:35Cancer patients and others are facing terrible and deadly diseases and are suffering more after promising clinical trials have been canceled. are rising every day and the Trump administration is only making things harder and more expensive for American families.

36:49The Republican majority in Congress could have done more to stop it but has enabled President Trump in ripping off the American people. I'm glad that we're holding a hearing today. The high cost of oral chemotherapy needs fixing and it sounds like we're aligned on some of those issues but that's just one piece of our health care challenges.

37:13Countless medications are out of reach for far too many families. This is the very first hearing on high drug costs in the subcommittee, and it's the last hearing this committee will hold before Americans go to the polls to elect a new Congress We should remember that this is far too little and far too late Thank you I yield back OK

37:35I don't exactly want to respond to that, but I will say this. This hearing is focused on oral chemo. We know there are people who feel it would be better if the government took over the entire health care system.

37:49That doesn't work anywhere else that I'm aware of. There's been tons of fraud, and more fraud will be soon shown in the current Medicaid system, saving billions of dollars. And I am going to, from here on out, just say that having the government run anything doesn't seem to work very well.

38:12It's why our country is so much wealthier than other countries. And we will continue to try to work to improve the current system. But right now, we're going to focus on community oncology. I'd like to welcome today's witnesses.

38:27Mr. Ted Okun serves as executive director for the Community Oncology Alliance. Mr. Okun is a nationally recognized expert on the policy and politics of cancer care, with an expertise in costs of cancer treatments, health care reforms, pharmacy benefit managers, or PBMs, and the changing landscape of cancer care delivery in the United States.

38:48Then we have Dr. Sheedal Kirchner, a practicing oncologist and associate professor of medicine at Northwestern Medicine. Dr. Kirchner also serves as the clinical practice director and medical director of the Cancer Survivorship Institute of Northwestern's Robert H.

39:06Lurie Comprehensive Cancer Center. In this role, Dr. Kirchner oversees a program spanning clinical survivorship care and research long-term effects of cancer treatment. And finally, Dr. Anthony Wright, Executive Director of Families USA, a national healthcare consumer advocacy organization.

39:26Before joining Families USA, spent 22 years as Executive Director of Health Access America. Thank you all for joining us, and I'm going to look forward to your testimony. Now, pursuant to—oh, by the way, I also want to submit for the record a statement from from the International Myeloma Foundation.

39:45I have currently a very loved family member who has myeloma. We have a statement from the Cancer Support Community who wanna submit for the record, and a statement from the record from Susan G.

39:57Komen on unequal treatment, addressing the drivers of unaffordability of oral chemotherapy. Now, pursuant to Community Rule 9 , the witnesses will please stand and raise your right hand. I solemnly swear to affirm that the testimony that you are about to give us is the truth, the whole truth, and nothing but the truth, so help you God.

40:24Let the record show that all the witnesses answered in the affirmative. take a seat and we'll first call on Mr. Olkin. Thank you Chairman Grofman, acting

40:40ranking member Randall and members of the committee thank you for the opportunity to testify today. I'm the executive director of the Community Oncology Alliance, a nonprofit organization advocating for cancer patients and the independent practices providing the highest quality and most affordable cancer care close to home.

40:54I want to begin with a core principle. A cancer patient should not pay more for their cancer drugs simply because the medicine that may save or extend their life comes in a pill rather than an IV bag.

41:11Yet that happens today. Cancer treatments change dramatically. Roughly one-third of cancer therapies today are oral and that share continues to grow. But because oral cancer drugs are generally covered under the pharmacy benefit, while infused or injectable drugs are covered under the medical benefit, patients can face very different and sometimes higher out-of-pocket costs simply because of how their cancer medicine is administered.

41:39That makes absolutely no sense. COA supports the goal of Cancer Drug Parity Act, HR 4101, which requires employer-sponsored health plans to provide cost-sharing for oral cancer drugs that is no less favorable than cost-sharing for cancer drugs administered by a health care provider.

41:57Importantly, the legislation also prevents plans from achieving so-called parity by simply increasing what patients pay for infused cancer drugs. Congress must pass that protection. But I strongly urge Congress to view parity as only the beginning of the discussion, not the end.

42:18Parity is just the floor. Access and affordability are the goal. If a patient pays thousands of dollars for a medically necessary cancer drug it offers little comfort that the coinsurance is technically equal to another benefit Our collective goal should be to minimize the financial burden on patients receiving potentially life-saving cancer treatment.

42:39And there is another equally important problem with potentially life-saving cancer drugs. A cancer drug that a a patient cannot actually obtain is no more accessible than a cancer drug that the patient cannot afford.

42:58Today, insurers and their pharmacy benefit managers place obstacle after obstacle between patients with cancer and the medications prescribed by their oncologist. Prior authorization all too often delays treatment. Fail-first step therapy can require a patient to try and fail a planned preferred drug before receiving the therapy the treating oncologist believes is optimal.

43:25Restrictive formularies often exclude drugs or place them on unfavorable tiers. Patients can be forced into insurer PBM specialty and mail order pharmacies rather than receiving their medications directly from the oncology practice coordinating their care.

43:41And patients successfully receiving a treatment can face non-medical switching simply because the insurer or the PBM changes its formulary. COA's 2026 survey of community oncology practices found that more than 96% of respondents had observed patients with cancer struggling as a direct result of insurer-imposed step therapy.

44:05The same percentage reported that insurance policies interfere with patients receiving and the treatment, their physician recommends first. For patients with cancer, the concept of fail first is not only disturbing, but it's scary and devastating.

44:22Cancer is a disease where you effectively lose control of your body. You shouldn't lose control of the medication to save your life. A drug preferred on an insurer or PBM formulary is not necessarily the least expensive drug for the patient or the drug the oncologist believes is best.

44:40It is often the drug that generates the greatest rebate or financial return for the middleman. Cancer treatment decisions should be made based on the patient's diagnosis, biomarkers, prior therapy, comorbidities, expected toxicity, and the best clinical evidence They should not be driven by what drug generates the greatest financial return for the PBM or the insurer Congress should build on HR 4101 and other legislation intended to remove the costs, delays, and denials that prevent cancer patients from receiving their optimal cancer treatment.

45:11Congress should minimize percentage-based coinsurance for medically necessary cancer drugs. Inappropriate fail-first step therapy and non-medical switching should be prohibited. Prior authorization should be dramatically streamlined with enforceable deadlines, meaningful exceptions, and review by physicians with real oncology expertise.

45:31Insurers and PBMs must be stopped from steering cancer patients to affiliated mail order and specialty pharmacies simply because the most profitable to the middlemen, the corporate middlemen. Let me close with this. Cost parity is the floor.

45:40Access and affordability are the goal because parity without access and affordability is not really parity. Cancer patients should not have to fight their cancer, fight unaffordable cost-sharing, and then fight an insurance company or PBM simply to receive the medicine their doctor prescribed.

46:06Congress can and must change that. Thank you, and I look forward to your questions.

46:12Now we'll call on Dr. Kircher for your statement.

46:15Chairman Grothman, Ranking Member Randall, and members of the subcommittee, thank you for the opportunity to testify. My name is Dr. Sheetal Kircher. I'm a medical oncologist at Northwestern in Chicago, where I treat patients with gastrointestinal cancers.

46:30I'm here today because my patients are not only dealing with their cancer diagnosis, but they're trying to figure out how they're going to afford the drugs that I'm prescribing them. Cancer treatment has changed dramatically.

46:40when people think about those receiving chemotherapy, they often imagine a person in an infusion center receiving an IV, but increasingly, some of our most effective drugs are pills taken at home. And sometimes this pill isn't just an alternative, convenient switch.

46:58It's sometimes the best treatment or the only treatment that is appropriate for that patient. And our insurance system has just not kept up pace with that science. An IV drug, like we've all mentioned, covered under our medical benefits and oral drugs covered under the pharmacy benefits.

47:13This is not just a technicality of insurance design to a patient with cancer. It determines whether they actually get their treatment. And so this is what it looks like in my clinic On Wednesday August 26 I was walking down the hall of my clinic to see Susan 62 year old school teacher She was a wife grandmother had about eight grandkids and also has metastatic pancreatic cancer.

47:39I was holding the printout of her scans, walking into that room and that scans, they showed that her cancer was growing despite the IV chemotherapy I was given. After 17 years of doing this work, I still have to pause when I walk into those rooms.

47:53I take a deep breath, knowing that the words are going to take away some of her hope and force them to once again confront her mortality. And literally, as I'm walking into that room, I step in, I receive a notification on my phone, and it's an FDA has just approved DREXORACIB, a new treatment for metastatic pancreatic cancer.

48:16And for a few minutes, that room was purely filled with hope that there was something that was going to give Susan just a little bit more time. That hope is quickly followed by a reality I knew was coming, that prescribing the drug and getting the drug are two different things.

48:33With her IV chemo, my infusion center, obtain authorization, patient shows up for chemotherapy, we administer the treatment, and it goes through her medical benefits. the experience is completely different for a patient receiving oral drugs with IV the patient may absolutely have co-pays and co-insurances and those costs can be significant but most have a supplement coverage or an employer-based plan design that limits the amount they pay at the point of treatment the patient is not standing at our infusion center door being told before we hang your bag of chemotherapy, you need to pay $1,000.

49:14And for oral drugs, that experience is really quite different. The specialty pharmacy processes a prescription, determines the out of pocket responsibility, which can be substantially higher than the medical benefit. That cost becomes apparent before the drug is dispensed.

49:30Too often, our health system specialty pharmacy is out of network, even at a large institution. the prescription to a PBM-owned pharmacy, separating the dispensing of these expensive, toxic drugs, and really divorcing them from the oncology team, which is providing the education and the care to the patient.

49:49And the patient can essentially receive a phone call saying, we have your cancer medication. Your responsibility is $1,000. How would you like to pay for that before we ship it? If they can't afford that amount, the drug is not dispensed, and we are left trying to find another way to pay for it.

50:06And we know this cost matters. In a study of over 10,000 patients prescribed these drugs, if the out-of-pocket cost was over $500, they were four times more likely to abandon the drug than if it was $100 or left.

50:20And in oncology, a prescription that a patient can't afford is not a treatment. IVs also mean transportation, parking, waiting rooms, hours, and infusion centers, not for the patient alone, but also for their loved ones.

50:37And oral drugs face additional obstacles. They require prior authorizations, formularies, step therapy changes, and really require to go through other particular PBM often own specialty pharmacies. The amount of time my nurses and advanced practice providers spend doing this, in addition to myself, is extraordinary when this is time we should be spending with our patients.

51:01And I understand that the Cancer Drug Parity Act doesn't solve all these problems. It doesn't eliminate prior authorizations, and it doesn't solve our PBM issues, but it does fix something very specific that has never made sense to me clinically.

51:11As an oncologist, I choose treatment based on biology, science, expected benefits, toxicities, and what matters to that person sitting right in front of me. Sometimes it comes through an IV, and sometimes it's oral.

51:31On August 26, Susan did not choose whether her breakthrough was going to be developed as an infusion or a pill. She should not experience a completely different financial reality because her next treatment is swallowed instead of infused.

51:46That's why the Cancer Drug Parity Act matters to me, the science to determine the treatment.

51:55Okay.

51:59Mr. Wright, I guess like the others, we'll give you five and a half minutes. Thank you, Chairman Grothman, Representative Randall, and members of this subcommittee. Thank you for having me here on behalf of Families USA, the national nonpartisan healthcare consumer advocacy organization.

52:14We appreciate the committee's interest in addressing the drivers of the unaffordability of cancer treatments and ensuring that oral chemotherapy is appropriately covered. Cancer impacts millions of American families More than two million cancer cases will be diagnosed this year alone including my wife just a few weeks ago As I and millions more know personally a cancer diagnosis is frightening enough on its own.

52:37No family should have to fight a second battle over how to afford the treatment. Even for people with private coverage, the cost of anti-cancer drugs can be staggering. Take Keaton Herzer, a 34-year-old from Colorado who was diagnosed with rare bile duct cancer.

52:57The day before his infusion of a targeted therapy, his health plan denied coverage, despite his oncologist's recommendation and advocacy. Rather than delay what could jeopardize his shot at a much needed liver transplant, Keaton and his wife emptied their savings account and paid for it out of pocket.

53:13$77,000 for a single treatment. Take Jen Jobe, a Texas teacher who beat stage four colon cancer and is now saddled with major medical debt. The cost of a single chemotherapy treatment was enough to reach her $8,500 annual out-of-pocket maximum.

53:32Over the course of treatment, she racked up $40,000 in out-of-pocket costs, despite her employer on-the-job benefit. These stories illustrate the big cost of cancer care, the need to be covered, and for that coverage to be comprehensive without delays, denials, sky-high deductibles, or other cost barriers.

53:52Health plans certainly need more oversight, especially of benefit designs developed in corporate boardrooms without public input as they seek to minimize their risk and shift the cost onto the consumer. Congress should follow the lead of state marketplaces that set standardized plans to ensure essential benefits and fair and value-based cost sharing.

54:11More than half the states have also passed copay caps for prescription drugs, with eight that have specific caps for specialty drugs, like oral chemotherapy. Similarly, 43 states have passed parity laws, so cancer patients don't face different financial barriers for IV-administered treatments versus oral chemotherapy, often covered in a separate drug benefit with its own deductibles, specialty tiers, co-insurance, and other cost-sharing.

54:38We support the Chairman's Bipartisan Cancer Drug Parity Act, which covers federally regulated employer plans that states can't touch, and other efforts to ensure that all coverage is comprehensive and cost sharing is limited Yet cancer patients with non plans also need comprehensive coverage Yet 10 million Americans are projected to lose coverage because Congress cuts to Medicaid and the Affordable Care Act Just this year 4 million Americans dropped their individual coverage due to the doubling of premiums resulting from the deliberate decisions to end the enhanced tax credits.

55:13A few million more dropped down to bronze plans with deductibles of $7,000 or more. We urge this committee to consider the millions of newly uninsured and underinsured, including those who will inevitably become cancer patients and face the full cost of cancer care.

55:31For all consumers, regardless of how or whether they are covered, we must confront the inflated and irrational prices of prescription drugs. Nearly one in three adults report not taking their medications as prescribed, rationing, skipping doses, not filling their prescriptions at all.

55:46An estimated 125,000 people die each year as a result. companies have long exploited a system that lets them set a high launch price with no accountability and then raise prices faster than inflation. Thankfully, Medicare drug price negotiation and a new $2,000 out-of-pocket cap is starting to lower drug costs for millions of seniors and people with disabilities, but the inflation reduction to acts negotiating power is limited to Medicare.

56:09We must expand negotiation to more drugs and to more people, including with commercial coverage. Congress must also shut down problematic pricing and practices like patent gaming and pay-for-delay tactics that keep cheaper generics and biosimilars out of the market.

56:26In closing, Americans are urging action on prescription drug prices and health care costs in general. Our Families USA poll last month showed that 94% of voters said it is important that Congress and the President act on health care costs.

56:4174% said very important. They want Congress to address affordability and hold the health industry accountable, from the drug companies to the health plants to the providers to the PBMs. Cancer patients like Keaton and Jen deserve more than parity between two unaffordable treatment options.

56:58They deserve a system where the cost of staying alive also doesn't threaten their family's financial future. Thank you, and I look forward to your questions.

57:12OK. I'd like to thank you all very much. Now we're going to the question and answer. I also want to give a little shout out before we start as far as the overall cost of drugs I know it you know drug by drug but Trump Rx is the first time in the 12 years that I've been here that we really had somebody willing to stand up to the pharmaceutical industry and drop the price of drugs and well that's not going to be as comprehensive is what we're going to talk about today it was a great step and I'd like to thank the president for that okay now we'll start the questions.

57:51I recognize myself for five minutes. Medicine has changed. More and more cancers being treated with oral medication that patients take at home rather than through IV infusions. For many patients, oral chemo is the safer, easier, and more effective option.

58:08But the way these drugs are paid for has not kept pace with a change. I'd like to ask both Mr. Dr. Okon and Dr. Kircher, can you explain in plain terms how our insurance rules have failed to keep up with the science and who ends up paying the price for this failure?

58:34Okay.

58:38So I think, Mr. Chairman, part of the problem is you identified in your remarks that the PBMs, basically three PBMs, control 80 percent of the prescription drug market. you have to realize each one of those PBMs is owned by an insurance company.

58:54In fact, in some cases, the insurance company owns the physicians as well, too, with United Healthcare. So the problem is that as these companies have seen these oral cancer drugs, and upwards of 30 percent, we're going on 40 percent of cancers are treated with oral cancer drugs, you have to realize that they are gold to these PBMs.

59:13They're gold, especially when they can extract rebates and do other mechanisms to make off of these drugs. And they always push the highest-priced drugs. So the fact of the matter is that this has attracted them to a market that is just going to increase, and it's just going to get worse.

59:39Yeah, I agree. And I think that cancer, in cancer specifically, the drugs have changed so much over the last 20, 30 years, where we did used to only have IV chemotherapy. And even in the 15 years that I've been practicing, the science has evolved into a space where not only orals, we're talking about the next level of now we're going to have, you know, a lot more immunotherapy, CAR-T therapy, different type of infusions that will need to keep up with this antiquated way that we really finance the chemotherapy, locking us into a bucket that really doesn't make sense for oncology anymore.

60:22Okay. The medical providers that are members of the Community Oncology Alliance or COA treat most of the cancer patients in our country. As COA's executive director, you've spent years fighting the industry practices that get between patients and their prescribers.

60:40Could you explain to us how PBMs and insurers often interfere with a patient's prescribed oral chemo treatment?

60:49It is terrible. First of all, when the drug is prescribed, if the insurer or the PBM with prior authorization does not agree with that, then the oncologist basically has to make a switch. Or in some cases, the insurer will basically say, you have to fail first on this drug, and in some cases, a couple times you have to fail.

61:14Think about a cancer patient and someone says you have to fail on that drug, meaning your cancer is growing, before you basically get the drug that they want. And again, I go back to the issue here.

61:25When you have three entities that control 80% of the prescription drug market, they are in a leveraged position to extract rebates, and therefore they look for the most expensive drugs, the drugs that they can profit the most from as the drugs that they want the patient to get, not what the oncologist wants.

61:48So it is a growing problem, especially as we have more oral drugs. Why didn't we see this 10 years ago? Because we didn't have the oral drugs that we have now. It's just going to get worse, and it's going to get worse until we do something about these PBMs and insurers.

62:04We've dealt with the PBMs and other hearings. Dr. Kircher, for some cancers, an oral drug isn't just more convenient. It's the treatment that works best, and it's the only option a patient has. When a plan makes this option unaffordable but covers the IV jug cheaply, are we forcing patients towards a more dangerous alternative And does the doctor who ultimately you know is your you relying on do they know what going on thank you for that question and

62:35I think that's a misconception that that they're that these drugs are alternatives they're actually completely unique identity you know identifiable drugs where I as a physician am NOT making a choice I don't have a choice oftentimes for an IV alternative.

62:52So there are times absolutely where I cannot get my oral drug quick enough, fast enough, and I will need to start patients on IV therapy because I can get it approved quicker. I absolutely agree with your question that yes, that oftentimes does put patients in a toxicity space that I would rather not them being in and I'm doing it mainly based on the fact that I

63:20need to treat their cancer quickly. Thank you. Okay, we've taken that time. Ms. Randall.

63:32Thank you, Mr. Chair, and thank you again to our witnesses for being here today. As I mentioned at the start, last year, HR1 was the beginning of stripping health coverage away from 15 million Americans.

63:44Rural hospitals, nursing homes, and community health centers who often are providing important life-saving health care to cancer patients are under severe strain, forcing many to reduce services or close them altogether. Many rural hospitals are choosing whether or not they can continue offering oncology and cancer services or if their patients are going to travel hours farther to go to another treatment center that still provides that care.

64:10Pregnant women being forced to travel greater distances to access maternity care, seniors struggling to find long-term care, people with disabilities experiencing serious disruption to essential services. Sarah in Tacoma, Washington wrote to me that she is a breast cancer survivor who was diagnosed with an aggressive form of the disease just before her 41st birthday.

64:32She credits decades of federally supported research with helping make her survival possible. And now at 44 and two years past active treatment, she continues to live with the fear of recurrence while watching for the next breakthrough.

64:52Her story is a reminder that research breakthroughs become life saving treatment and Congress must protect federal investments in cancer research and ensure that these treatments are affordable and accessible In the richest country in the world as the chair pointed out earlier that we are, it is unacceptable that we allow high out-of- pocket costs to stand between patients and the advances that research makes possible.

65:19Mr. Wright, my question is for you. Oral chemotherapy can be particularly difficult to access for patients in underserved communities where lower incomes, gaps in insurance coverage, limited access to oncology care, other barriers can compound and burden the high out-of-pocket costs.

65:36What do you see affecting most patients in rural low-income and other underserved communities

65:43and preventing them from getting access to care? Obviously the issues of access in rural health care is significant already. We do say, as you mentioned, that the cuts that were made last year, the biggest cuts in the history of the Medicaid program, will make that issue worse, especially for providers where Medicaid is the primary payer.

66:02And that includes rural hospitals, that includes maternity wards, that includes community clinics, and a range of other providers that will have to either scale back services or maybe even close as a result. I also think that these cuts have an impact both on moving people off of coverage, again, estimated millions of people who will face the full force of cancer costs if they do get cancer while uninsured or underinsured, and even if they are insured, they'll have a harder time getting access to the care that they need.

66:35And even trying to get through some of these bureaucratic burdens, you have a situation where the Trump administration has gone further than the law that was passed by saying that, yes, we're going to exempt people who are medically frail from these requirements, but we're going to actually have to have everybody go get a doctor's note.

66:54We're not going to blanket, say, folks with cancer have this. We're going to put additional bureaucratic burdens, even for cancer patients, to get the care that they need.

67:03Thank you so much for that perspective. As we know, the cost of health care can lead many to putting off much needed care. And it's not a red state versus blue state issue, right?

67:11I represent Washington State, but these huge cuts affect everyone. Texas hospitals are facing a roughly billion loss in additional Medicaid funding this fiscal year about 27 million a day Funding that helps hospitals cover the gap between Medicaid payments and the actual cost of caring for patients who need, often, expensive treatment.

67:40Mr. Wright, you shared so much about the patient experience with us. For oral chemotherapy in particular, how much of the financial burden patients face today is driven by the underlying price of the drug itself versus the way insurers structure coverage?

67:59I think it's both. I think the drugs are very expensive. And again, we give them a monopoly. But in many cases, they abuse that monopoly, that patent, with gaming to try to extend that monopoly to have more time to charge the monopoly price.

68:14And then the insurers pass that cost onto consumers and try to limit their risk with the types of benefit designs, and that's why we need to have oversight or benefit designs. Cancer parity is one example, but there's other ways to put caps or other ways to make sure that we have standardized plans so people have assurance that essential benefits are covered and they can do apples to apples comparisons.

68:37OK.

68:38Can I just a .. OK, sure. Unanimous consent. I'm done with my questioning. I asked for unanimous consent to enter into the record an article from The Guardian, which shows how TrumpRx is not a solution for the majority of patients dealing with high drug prices and also for unanimous consent to enter into the record a report from the protect our from protect our care which found that the Trump administration's actions threatened the closure of over 1,200 hospitals clinics and nursing homes jeopardizing access to care.

69:07Okay without objection I will say

69:15right now. We'll see how many more people show up for this subcommittee, but we are going to have two rounds of questioning. So if you want to hang around. Now we go to

69:24the great Paul Gosar. Well, as you both, all of you may not know, I was a dentist for 25 years, okay? So I was looking at marketplaces. So Mr. Wright, I'm going to ask you this question.

69:37How has a patent process really affected this? Because it, once upon a time, used to be first to discover instead of first to file?

69:47Again, I think we have a drug development process where those who file the patent get the benefit of several years of charging a monopoly price. I do think that the opportunity for Congress is to take a look at ways that that patent has been gamed, whether from patent gaming, trying to extend the patent, pay for delay settlements where they actually do settlements to the potential generic competitor to keep competition from the market.

70:17I think it's a preliminary force. And we have to go back to address this, because there was a law called McCarran-Ferguson, gave limited liability to insurers for that monopoly rule. but they were running a freight train through that thing.

70:30It was my legislation that repealed that. Now, I think we ought to be looking back at that one. Do you agree?

70:35I'm happy to take a look at it.

70:36Great, great, great. So what if I told you that part of this is the federal government's problem, Mr. O'Conn. So back in 2007, we knew that in cancer drugs, that the IL-15 was a marker that actually exposed the tumor.

70:54And then you can use your own genetics and your immune system to kill it off. That was known in 2007. Why don't we have this? Because we see now KTRUDA as being a K2 or as an I2 drug.

71:12It doesn't do that. And yet Antiva is one that exposes those tumors unless your body's immune system takes care of it. This has been known to 2007, the FDA. What is the problem? Why isn't this being directed and why is it so expensive?

71:30I can't really explain that, Congressman. I mean, the fact of the matter is that in the, and Dr. Kircher could talk about this.

71:40I'll come back to her.

71:41We have more drugs and more novel drugs. She talked about CAR-T and talked about not just the immuno agents that we see in terms of Keytruda and Opdivo, but we're seeing cellular therapies come out that are using the body's own mechanism to heal.

72:03And I think that basically you're gonna see a lot more of this, and they're very novel, and how we pay for those and the mechanism has to be looked at as well too. Because it's not just, as the chairman said, going from injectable chemotherapy that you think of traditionally to oral drugs, it's now cellular therapies and different things.

72:24And we have a payment mechanism that is archaic and not keeping pace I glad you said that because you know bringing in the ranking member comments I agree with her A lady with breast cancer why she wasn given a braxine I don know You know, it's criminal what's going on here, absolutely criminal what's going on here.

72:42So, you know, I think that we've got to start from the very bottom, increasing competition so that nobody can look. Don't allow any limited liability for the insurance companies. Make them compete. Make them compete.

72:55And we're so far behind. There's 34 countries, 35 countries I believe now, that give the exemption to ensure that they have a braxine and then you have this Keytruda. Doc, what do you see in your practice?

73:07I mean, really just echoing the sentiment up here is that we need innovation in cancer treatment. these types of treatments to move forward and they are expensive and they take a lot of research and development so you know comprehensive health care reform and price reform drug parity is just one piece of this very complicated puzzle knowing that stifling innovation is not what our cancer patients need but leaving behind a legacy of financial devastation also cannot be.

73:49And how do we find the middle ground?

73:53Exactly. I want to come back to that. We want to talk about the opportunity for the right to try. Why isn't it getting the vestige that it should be? Because I think there's a lot more to the story than meets the eye.

74:04I'll yield back and I'll look forward to a second around.

74:07I ask unanimous consent for a second round of questions for the members without objection, so ordered. You're not objecting, are you? Okay. First of all, I'll make a point outside of this. We may or may not have other people show up for the subcommittee.

74:32I'll make a point that we should do something about subcommittee attendance later on. Okay.

74:41I know.

74:46All the more importance for the people who do show up. Mr. Oaken, this is for you. 43 states in the District of Columbia have already passed oral parity laws I believe I voted for such a law when I was in the state legislature in Wisconsin But those state laws do not reach self employer plans So those states do not so those state laws do not reach self employer plans which cover roughly two-thirds of Americans.

75:12So, you know, if you're sitting back home and you hear this, you thought, wait, I thought my state took care of it. Not if you're part of a self-funded employer plan. The Cancer Drug Parity Act, which I reintroduced this Congress, closes the employer plan gap by amending ERISA so a plan covering IV anti-cancer drugs must offer cost-sharing for medically necessary oral anti-cancer drugs on terms no less favorable than the IV alternative.

75:37In practical terms, what changes would a patient at the pharmacy counter see if this bill becomes law?

75:43Well, I think the beauty of it is, Mr. Chairman, is that now on a federal level, you basically have parity for those self-funded plans. So it takes, it fills in the gap that you have with those 43 states that is just under state law.

76:00So I think it's an absolute step in the right direction. I think what we need to build on it, as I said, and Dr. Kirchner said as well too, is we need to build on it in terms of having no prior authorization and no fail first step therapy as well too.

76:15But everything we do, we have to understand, Everything that Congress does here is a step in the right direction in terms of PBMs and insurers and certainly oral cancer parity.

76:26Okay, Dr. Kirchhoff, I'm going to ask you this. Obviously, the current system is broken. We have people dying unnecessarily because they can't get the drugs they have. The question is, who exactly, because overall this should be, I would think, cheaper overall, right?

76:43because you're not going through this first step sort of nonsense in which somebody is paying the cost there, who is making the money off the current system at the expense of the patient? PBMs, drug companies, who is making the

77:01money? I think the answer to that question is yes, all of those at the expense of the patient. And so I think at every step in that chain that you just mentioned that there's inefficiencies and and unlikely abuse, you know, ultimately I know that what I seeing at the patient level and at the physician level is where things are suffering and that where it matters the most You know people are definitely not paying me more to handle these prior authorizations and answer the phone call from the patient and the numerous messages in the portal I receive of when is my authorization going to go through and me not having an answer for them.

77:52Okay, now there's obviously a lot of cost that goes into the current system. So common sense would say that overall, if this bill passes, it will be cheaper overall, right, if you could immediately go to the oral drug right off the bat.

78:08I wouldn't assume that necessarily oral drugs are cheaper or less cheap than IV drugs. Sometimes IV drugs are more expensive. It just puts them on, this legislation is excellent because it puts them on par with each other.

78:21So at least there's some transparency in how we are covering.

78:26I guess I'm trying to get to this legislation is not law today, and it's not law. Somebody would have introduced something in past sessions except for somebody's making money. So the question for you really is who's making the money?

78:42You can say who is making money on the current system that would stand in the way of this bill becoming a law?

78:50I think PBMs, and all the middlemen in between.

78:57OK, Dr. Ocon, I can see you wanting to say something.

79:02Excuse me, but when my wife listens to this and she hears you called me doctor, and she's the nurse, she will say there's only one medical professional in the Ocon family, and it's not him as much as he thinks he knows about oncology.

79:16So I appreciate your reference to the doctor. But let me say that who's making the money are the insurers and the PBMs in this. I mean, I'm not going to deny that basically launch prices are too high on the pharmaceutical company side.

79:31But you have to understand that they have an ordinate control. The top insurers are the top PBMs. So they have total control of the marketplace.

79:41So this vertical integration is part of the problem, too.

79:44Absolutely. Absolutely, and if I can say, consolidation, if you ask me one word to tell you what is wrong with our healthcare system, it's consolidation. And if you go online and you look at the COA prescription for healthcare reform 2.1, you will see its consolidation is our problem.

80:03I don't want to wander here, but the general perception that I know people around here is the current system, which was changed so much under President Obama, was largely written to benefit the insurance companies.

80:21And we have received private briefings on not only that, but the huge cost of fraud under the current system that is just through the roof. But in any event, we'll go for Ms. Randall for her second round.

80:38Thank you, Mr. Chair. I want to second the challenges of vertical integration and consolidation in the health care system. It's an issue that I worked a lot on in the Washington State Legislature when I was there.

80:52But Dr. Kircher, you were talking about your patients. You know, you see them on their hardest days having to make really tough choices about what they can afford, what kind of treatment they can afford to access.

81:09And I couldn't help but think of it. I had a friend who was diagnosed with a very serious and aggressive GI cancer before her 30th birthday. And Beth's way to get through it was to think about money as like monopoly money.

81:29She's like, well, either I'm gonna survive and I'll figure it out or I won't. And what does my credit card bill mean to anyone? which is a really challenging place to be for someone fighting for their life.

81:47As your patients are making these decisions about what they can afford, what other considerations are they sharing with you? Is it taking care of their children, their housing? What goes into making this decision about what's possible for them?

82:07It's really interesting when you talk to patients, they oftentimes won't bring up the finances. That you're sitting in front of them telling them the worst news of their life. And they don't want to share with their doctor that they're worried that they cannot afford the medications.

82:23They will put it on their credit card They will sell the house They will do whatever they can for that glimmer of hope And they don want me to make decisions based on whether or not cost is an issue.

82:35But there, you know, I oftentimes remind my patients and have to remind my team and myself that these patients have lives outside of these four walls, work didn't stop, although they may not be able to go to it.

82:49Their children still, you know, anyone who has a five-year-old knows that I don't know if they care if mom doesn't feel well mom's got to do what she's got to do and so child care continues work continues and the bills just keep piling up so when we talk about even a total you know an out-of-pocket cost of $50 $100 it's not the $50 it's not the $100 it's that amount of money sitting on a pile of direct and indirect costs And, you know, I wish that credit card bill would just go away, but really what it's doing, it's leaving a financial legacy to their kids and their spouse and their loved ones on top of them potentially passing from their cancer.

83:36Thank you so much. You know, Mr. Wright, you earlier enumerated a number of things that Congress could be doing to address some of the problems with rising health care costs. Can you share again some of your best recommendations so that we can ensure rising drug prices don't translate into patients delaying, abandoning, or going without treatment?

84:10Thank you, Congresswoman. I first start with coverage. None of this conversation means anything to people who are uninsured or underinsured. people who are uninsured, live sicker, die younger, or want emergency away from financial ruin.

84:22Reversing the cuts that have been made and trying to further expand coverage is a direction we need to go to properly honor cancer patients and make sure that they are covered. Secondly, once they're in coverage, that coverage needs to be comprehensive.

84:35And that means not have untold cost sharing barriers, whether it's because of its oral or IV, or just because it's a cancer treatment and it's thousands of dollars. And so having some review and oversight over benefit design, whether it's standardized plans, whether it's copay caps, or other things.

84:51But then basically, that is basically just a cost shift within the insurer to then shift onto other types of cost sharing or to premiums if you don deal with the base cost of why the drugs are so darn expensive to begin with and that means dealing with the issues of why drugs are so expensive whether it's with regard to patent abuse whether it's with regard to other issues of problematic practices of just or just even just having the government negotiate for the best possible deal like both President Biden and Trump did under the Inflation Reduction Act.

85:23That would be an appropriate way to expand that negotiating power to more drugs, to more people across the board.

85:33Thank you. I hope some of those recommendations are things we can work on bipartisanly. I just have one more UC request for you. I ask unanimous consent to enter into the record an article from Families USA highlighting how the Trump administration is prioritizing insurance companies over American families.

85:54Without objection. Okay, we'll call on Congressman Gosar one more time.

86:03Sounds good. Mr. Wright, would you agree with the statement I want to make here? Good process builds good policy builds good politics.

86:13Generally, yes.

86:14So we're talking about process. Now, I guess what we've looked at, we've seen Republicans try to do this comprehensive healthcare. We've seen Democrats try to do it and it's a failure all the time because I think we lack the aspect of working with our federal system.

86:27The incubator is called states. I think we really need to do this to find out how it works, how it's working for them and what one may work in Arizona doesn't work in Washington State.

86:38It may work in California, it doesn't work in New York. We've got to tailor it to that to that mention and we don't know those answers until we do that. Would you agree? I've been a state advocate for

86:49for 30 years before taking this job, I absolutely agree.

86:52Mr. Akron, do you agree with that? Yes. How about you, Doc?

86:59Generally, yes.

87:01Well, so I'm looking at this, and I empathize with you so badly, because you're forced subconsciously, especially when you belong to a network, you're subconsciously geared towards that, what you know is being paid for and not being paid for, right?

87:19Does that make sense to you? So this is vertical integration They own the docs they own the pharmacies they own the hospitals and you forced to do that So it subconsciously puts you in a predicament Well I know what they going to be paid for so they can get this compensated, but it may not be the treatment of choice.

87:39Correct, yeah. You know, when we are oftentimes playing that calculus in our head as far as I need treatment fast, and what am I going to be able to get authorized quickly? Oftentimes we don't have that luxury of options, but yes.

87:55Boy, we're in a real mess here because this is just a sticky wicket. Because if you look everywhere, there's a problem. When you look at the states, the Federalists, Mr. Wright, how would you go about doing that?

88:13Teach us something we may not know.

88:15I think I would look at states and what they're doing. Again, I mentioned my past experience as as a consumer and patient advocate in California, where in Covered California, they actually have a public process where the insurance benefit design is not done in the corporate boardroom, it's done in a public process that includes providers, that includes patient advocates, includes the plans themselves, and they have a little bit of a straight jacket of trying to hit benefit designs that hit 70, 80, 90% of actuarial value, and so there are real trade-offs, but then they can decide, hey, in order to have the most valuable benefit for folks, let's actually put primary and preventive care in a tier that has the least cost sharing possible, no cost sharing at all, even if that means a slightly higher hospital benefit.

89:03It means dealing with some of the inequities between IV versus oral treatments, so there isn't this weird dislocation where the doctor's trying to not just give the best clinical advice, but also trying to help the patient with the financial advice, which is not the forte of a doctor.

89:18And I think that kind of public process is actually really important when setting standardized plans. That's something. So I do believe in the federal system when let states experiment. But when you have an idea that's working, then take it federal across the land.

89:32And I think we're trying to do that with the cancer parity law, which is done in 43 states. But we need to fill the gap for the federal plans and other things like that.

89:43Well, see, I get to this point where that the federal government doesn't know all. And I think we put artificial restraints in when we don't think we're doing it at all. And so I like the marketplace, but I want the compassionate aspect.

89:56So I don't know how to get that. Do you understand where I'm coming from? You know, I want the system to work, but I want the patient to be the center focus. Because she's put in a quandary as a doctor.

90:08She is put in a quandary. I want her to be able to say, listen, this is the best mechanism, best drug for you. Here's how we get it.

90:17I actually, again, agree with you in one point, which is I do actually think that some of these kinds of public things will actually allow the marketplace to work better. if you actually have clear standardized plans, consumers can actually then make apples-to-apples comparisons rather than be confused by different plans.

90:30A person who's buying a coverage today has no idea if they're gonna get bio, what kind of cancer they're gonna get, or whether they should check to see if this plan does better with covering oral versus IV.

90:43That's not something that should be in somebody's mind when they're doing comparisons. So first step

90:51for you would be parity with ERISA, right?

90:54I would, I think you either do the good things at the federal level or you allow states to lift the floor.

91:03Well, doesn't that, challenging ERISA, allow you to go to the states more often?

91:07What?

91:09Doesn't breaking down ERISA actually allow you to work with states more broadly?

91:14I think you could go in either direction. You can either allow states to do more putting the floor in place or past the rights and consumer protections at the federal level Okay Well I thank you very much I appreciate it

91:29Thank you very much. In closing, I want to thank our witnesses again for your testimony. Now we're going to go to closing remarks. Ms. Randall?

91:42Yeah, I just want to thank you all for bringing your best ideas today to this discussion. You know, healthcare is such a vital issue for all Americans across the country, folks in red states and blue states and rural communities and urban communities, providers who are trying to keep their doors open and help their patients access the care that they so need, and families who are making tough decisions about what they can afford.

92:05And I think it's definitely our responsibility to ensure that all everyone has all the tools that they need to not just survive but thrive and that means ensuring that health care is not a a direct uh ticket to bankruptcy for families who are dealing with really severe challenges

92:33thank you so much yield back um we had several committee hearings dealing with health care on on the subcommittee and on the committee as a whole And it always very depressing to hear the degree to which greed drives our health care system.

92:54And this is one of the most extreme examples of that. So I'm glad we had this hearing today. I hope the people who have been up here remember what they hear on this hearing.

93:08I will never forget it. And because it's the last hearing prior to the election, I don't think my bill will pass this session. But hopefully the people up here can, I think all of you, view it favorably.

93:26We'll see what we can do to make sure it passes last time. I heard similar testimony to this 14 years ago when I was in the Wisconsin legislature. And Wisconsin is one of the whatever, 42 states or however many states have tried to do this.

93:47And like I said, you hear about all these doctors and whatnot, big insurance executives, And when you're sitting there as a patient, and you, if somebody at home watching this hearing it depressing to hear how much which one will make us more money drives the system and sometimes inadvertently I like to actually talk to Dr Kircher later about something or other in these lines.

94:14In any event, I want to thank our witnesses for their testimony today. I now yield, oh, we take care of that. With and without objection, all All members have five legislative days within which to submit materials and additional written questions for the witnesses.

94:34If there is no further business, without objection, the subcommittee stands adjourned.