Lawmakers in the nation's capital have yet to grapple with rising drug costs, but Ohio voters are being asked — in a single ballot-box question next week — to figure out how best to lower the tab the state pays for prescriptions.
The Drug Price Relief Act, better known as Ohio Issue 2, has been promoted and pilloried in a dizzying crush of robocalls, TV and radio ads, and direct mailings.
Opponents say it is impossible to implement, could limit patients' access to medicines and would not necessarily save money. Proponents are selling the initiative as a rebellion that could save millions of dollars in an era of health care anxiety.
And, as Election Day approaches, voters say it's difficult to make sense of it all.
Sean Hundley, a 30-year-old Medicaid beneficiary who works at a coffee shop in Columbus' trendy Short North neighborhood, said he has seen plenty of advertising from both sides, but he can't figure out who is telling the truth.
"Everything they say, not knowing who to trust — it would just lead me not to cast a vote," he said.
This reaction highlights one of the difficulties of tasking voters with sorting out such a complex issue. But what they decide will likely have implications well beyond the state's borders.
In the absence of federal action, states have begun taking legislative steps to address the toll of rising drug costs on their budgets — a trend that raises concerns among pharmaceutical companies.
If Issue 2 passes, this ballot-question strategy may also gain momentum. Advocates in South Dakota and the District of Columbia are already pushing for such a drug pricing initiative in the November 2018 election.
But California voters rejected a similar measure last year, noted Jane Horvath, a senior policy fellow at the National Academy for State Health Policy. A second failure could have a chilling effect on the idea of using the ballot to push drug-pricing reform, she added.
That's part of the reason why this ballot-question campaign has drawn attention and contributions from outside the state. Supporters have raised more than $14 million, with most of that money coming from the California-based AIDS Healthcare Foundation. Opponents, bankrolled by the pharmaceutical industry, have raised $58 million.
But during a recent water aerobics class at a suburban Cincinnati gym, participants — mostly women who said they were reading daily newspaper coverage and watching local news to figure out how to vote on the ballot initiative — said they were fed up with all of the campaign noise.
The exercisers — fit, mostly retirees bouncing up and down in the water — even peppered a reporter with questions: Do you understand it? Can you explain it to me?
If enacted, Issue 2 would prohibit state programs, such as Medicaid and state employee health plans, from paying more for a medication than does the federal Veterans Health Administration. The Department of Veterans Affairs receives heavily reduced prices for prescription drugs.
But analysts are divided over whether this would work, or what amount of relief it could provide to the state budget.
An analysis by the nonpartisan Ohio Office of Budget and Management said it's unclear whether the change would actually save any money and, if so, how much.
Supporters, who include Vermont Sen. Bernie Sanders and Ohio's former Republican Party chairman, counter that their calculations indicate savings of about $400 million — and that, they say, is why drug companies have spent so much fighting the initiative.
"Our opponents say it's unworkable or — they've created a word — 'unimplementable.' We believe it will work," said Dennis Willard, a spokesman for the Yes on 2 campaign.
Meanwhile, critics worry Issue 2 would be nearly impossible to enforce.
For one thing, the VA's final discounts are deemed proprietary and kept secret. For another, it's unclear which state agencies would be included under the initiative.
In addition, the state's Medicaid program already receives discounts from drug companies. Unlike the VA, though, federal law requires it to cover the vast majority of drugs, making price negotiation more difficult.
"You can't get the VA prices if you don't do VA things," said Walid Gellad, co-director of the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh. "To just say, 'We're not going to pay more than the VA' is difficult."
But those are nuances that are tough to explain in a radio spot, or on a mailed flyer. And that means the dueling media blitz is leaving many Ohio voters at a loss.
Take Barbara Herr, a 64-year-old paralegal. She's a lifelong Democrat, she said, and in some ways the issue's target voter: a self-described "political junkie" who voted for Sanders in his presidential campaign.
She has a shellfish allergy so she carries an EpiPen — a medication for which drugmaker price hikes sparked national scorn and a congressional hearing. Even though the ballot question would not likely directly affect her medication spending, she thinks prescription drug pricing is a "grave concern" and must be addressed.
So far, though, she's a likely no vote.
"It just is very confusing," Herr said, reflecting on her impending Election Day decision. "I have read quite a bit about it, and I don't think it achieves much of anything."
In some ways, experts said, this response is to be expected.
Drug pricing is complex and already has caused head-scratching among policymakers and academics, noted Rachel Sachs, an associate professor of law at Washington University in St. Louis, who studies the issue. In a recent congressional hearing, lawmakers struggled to identify the key source of price spikes, or the best place to attempt regulation.
"Confusion is a very normal thing to feel when looking at this," Sachs said. "And a concern I might have is whether the parties on either side, when they're spending on advertisements — either for or against the initiative — are really seeking to stoke that confusion."
KHN's coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.
This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.