Story at a glance

  • In 2020, questions about health care access — and who should pay for it — will be front and center.
  • Health care costs are higher than ever, especially when it comes to prescription drugs.
  • The opioid epidemic has impacted the lives of millions of Americans and dozens of states — and it will remain a big issue in 2020.

A new year and a new decade have begun — and health care looms as one of the nation’s most important and costliest issues. Here are the most important challenges we’ll be wrestling with in 2020, with brief explanations of what they mean in the grand scheme of things.

Health care access

Health care (and who should pay for it) has already been a major topic at the Democratic debates in 2019. In 2020, we’ll hear even more about why this is a crucial issue.

During the 2019 enrollment period through the Affordable Care Act (ACA), more than 4.4 million people selected health insurance plans or were automatically re-enrolled. The number of uninsured people in the U.S. is down since the Affordable Care Act, but millions are still not covered. In 2018, about 27.8 million nonelderly Americans were uninsured, many citing that health insurance premiums were too expensive. Although many Americans are covered by employer-provided health insurance, even among this group many are under-insured. This means that their insurance doesn’t adequately cover the costs of health care for them. For example, premiums could be high where someone’s monthly payments are too expensive or a high deductible that means a person would have to pay for health services up until a certain amount before insurance kicks in.

To get uninsured people covered, some politicians have suggested a Medicaid-for-all plan in which the government would provide health insurance for everyone, most notably Sen. Bernie Sanders. The Democratic presidential candidates generally support ACA and some support “Medicaid for All” or other plans in which people could opt into a Medicaid plan if they don’t have insurance through an employer. Some states are working to expand who may qualify for Medicaid and looking to allow people to buy into a Medicaid plan, including Washington, Oregon, Nevada, Massachusetts and New Jersey. People can search through or a similar health care marketplace set up by their state to shop for insurance plans. And plans for 2020 have gotten cheaper, reports NPR.

What happens when a person can’t pay their medical bills? They may end up thousands of dollars in debt and their hospital might take them to court for not being able to keep up with payments. About 137.1 million people in the U.S. reported financial hardship related to medical reasons. One study found that 66.5 percent of bankruptcies are related to medical issues. Some presidential candidates are proposing solutions like providing Medicaid health care to everyone or allowing people to buy into such government-run health insurance plans. It’s likely that a combination of solutions is necessary, including plans to help lower the cost of medication.

Drug costs

The topic of drug costs is related to health care access but deserves its own discussion. Part of the issue is with patents and pharmaceutical companies that have monopolies on drug pricing of their patented products. Another part of the problem is the lack of regulation of generics for quality by the Federal Drug Administration.

One of the biggest topics we’ve heard about this year has been the high cost of insulin in the U.S. compared to other countries. A vial of insulin could cost $300 in the U.S. compared to $20 in other countries. In July, Bernie Sanders took a group of people to Canada to buy insulin. People may be able to buy older versions of insulin, but it’s harder to use and may not be as effective for them, potentially endangering their lives.

Another example is the cost of PrEP, which stands for pre-exposure prophylaxis and is used to prevent HIV infection. Drugs used for PrEP are also less expensive in other countries. An individual taking Truvada for PrEP could pay almost $2,000 a month for the medication in the U.S. compared to $8 in other countries. Rep. Alexandria Ocasio-Cortez brought this up recently in a hearing, specifically targeting the company Gilead, which makes Truvada, a drug used for PrEP. One of the reasons why prices are so high in the U.S. is because holding patents gives drug makers a lot of power.

With patents, drug companies are the exclusive sellers of their patented drugs when they first come on the market for a period of anywhere between six months and seven years. And they can increase prices pretty much whenever they’d like. When the patents reach the end of the exclusive period for the inventors, generic drugs can enter the market. Even for more affordable generic drugs, we need to worry about the quality of those generic drugs and the conditions in which they were produced. It could also be clearer to us consumers that generic drugs are not carbon-copies of the name brand drugs but are often reverse engineered and may not function the same way.

In 2019, the House attempted to pass a drug pricing bill several times but they have all failed. Although it is proving difficult to get the details right to get enough support for such a bill, there will be another chance to get it through in 2020. A drug pricing bill, H.R.3 - Elijah E. Cummings Lower Drug Costs Now Act, passed in the House on Dec. 12, but the Senate has indicated that they will not take it up. This particular bill could still gain bipartisan support in 2020, but Sen Majority Leader Mitch McConnell openly opposes it.

Meanwhile, at least 33 states passed laws in 2019 to address drug pricing. The new laws allow importing prescription drugs, screen for price increases and establish oversight boards. Colorado, Florida, Maine and Vermont passed laws to import cheaper drugs from Canada, but that may not be a long-term solution.

At the federal level, H.R.3 would allow the Centers for Medicare & Medicaid Services to negotiate prices of certain drugs, including maximum prices for insulin and brand name drugs that don’t have generics. It also explicitly compares prices of the same drugs in other countries like Canada and Australia, setting the maximum at 120 percent of the average price. This law could at least ensure some affordable options to consumers and get the pricing under control for some drugs, its supporters say.

Opioid addiction

Opioids are a very potent class of painkillers. Doctors will typically only prescribe them in severe cases, but they are highly addictive. Some report that it only took one pill to get them hooked. By 2018, an estimated 10.3 million Americans were misusing opioids, including pain relievers and heroin.

The opioid epidemic has been ramping up with increased opioid use for pain relief since the 1990s. Drug makers claimed that opioids were not as addictive and were being prescribed to treat chronic pain in addition to short-term pain. The Centers for Disease Prevention and Control (CDC) estimate that every day more than 130 people in the U.S. die after overdosing on opioids. In 2017, more than 47,000 people in the U.S. died from opioid overdoses, according to the CDC. 

One area of crisis for opioid addiction relates back to the health care access problem. Treatment of opioid use disorder and mental health are separate from mainstream health care, which has “created obstacles to successful care coordination,” according to a report from the surgeon general. Many opioid users end up in the emergency departments of hospitals all around the country. In some cases, their addiction has led to losing their jobs and burning bridges with family members.

There are a few medications available to help people with addiction, including buprenorphine and methadone. These medications are different from naloxone, which is used to reverse an overdose, because they are taken regularly to reduce opioid use. But health professionals are sometimes reluctant to use these medications.

Data for the opioid epidemic show that since 2015 the total number of people using opioids may be decreasing from 2.37 million to just over 2 million in 2018 (this includes heroin users) but the number of people seeking treatment for opioid abuse has been increasing steadily since 2006 to more than 682,000 people in 2017. New York State reports that the death rate for opioid overdose got significantly worse between 2015 and 2016, going from 10.8 deaths per 100,000 people to 15.5.

In 2019, drug companies that make and market opioids came under fire for their role in the opioid crisis, especially for pushing the drugs on doctors and claiming that patients wouldn’t get addicted. Several state and local governments have lawsuits against drug companies like Purdue Pharma and Johnson & Johnson. Purdue Pharma filed for bankruptcy in September and the company has not admitted to any wrongdoing regarding the marketing of opioids to doctors and patients. The Sackler family, who own Purdue Pharma, offered to settle by giving up control of the company and paying $3 billion to help communities cope with the opioid crisis. Some states have agreed to the settlement though nothing has been confirmed and there are also individual lawsuits against members of the Sackler family.

More to come

If you are interested in learning more about these issues, look forward to original reporting on these issues on Changing America in 2020!

You can follow Chia-Yi Hou on Twitter.

Published on Jan 02, 2020