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Democrats’ Long-Sought Plan for Lowering Drug Costs Is at Hand

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WASHINGTON — For decades, as prescription drug costs have soared, Democrats have battled with the pharmaceutical industry in pursuit of an elusive goal: legislation that could drive down prices by allowing Medicare to negotiate directly with drug makers.

Now they are on the verge of passing a broad budget bill that would do just that, and in the process deliver President Biden a political victory that he and his party can take to voters in November.

Empowering Medicare to negotiate prices for up to 10 drugs initially — and more later on — along with several other provisions aimed at lowering health care costs, would be the most substantial change to health policy since the Affordable Care Act became law in 2010, affecting a major swath of the population. It could save some older Americans thousands of dollars in medication costs each year.

The legislation would extend, for three years, the larger premium subsidies that low- and middle-income people have received during the coronavirus pandemic to get health coverage under the Affordable Care Act, and allow those with higher incomes who became eligible for such subsidies during the pandemic to keep them. It would also make drug makers absorb some of the cost of medicines whose prices rise faster than inflation.

Significantly, it also would limit how much Medicare recipients have to pay out of pocket for drugs at the pharmacy to $2,000 annually — a huge benefit for the 1.4 million beneficiaries who spend more than that each year, often on medicines for serious diseases like cancer and multiple sclerosis.

Lower prices would make a huge difference in the lives of people like Catherine Horine, 67, a retired secretary and lung recipient from Wheeling, Ill. She lives alone on a fixed income of about $24,000 a year. Her out-of-pocket drug costs are about $6,000 a year. She is digging into her savings, worried she will run out of money before long.

“Two years ago, I was $8,000 in the hole,” she said. “Last year, I was $15,000 in the hole. I expect to be more this year, because of inflation.”

Between 2009 and 2018, the average price more than doubled for a brand-name prescription drug in Medicare Part D, the program that covers products dispensed at the pharmacy, the Congressional Budget Office found. Between 2019 and 2020, price increases outpaced inflation for half of all drugs covered by Medicare, according to an analysis from the Kaiser Family Foundation.

The budget office estimates that the bill’s prescription drug provisions will save the federal government $288 billion over 10 years, in part by forcing the pharmaceutical industry to accept lower prices from Medicare for some of its big sellers.

Opponents argue that the measure would discourage innovation and cite a new analysis from the budget office that projects that it would actually lead to higher prices when drugs first come on the market.

Drugs for common conditions like cancer and diabetes that affect older people are most likely to be picked for negotiations. Analysts at the investment bank SVB Securities pointed to the blood thinner Eliquis, the cancer medication Imbruvica and the drug Ozempic, which is given to manage diabetes and obesity, as three of the first likely targets for negotiation.

Until recently, the idea that Medicare, which has about 64 million beneficiaries, would be able to use its muscle to cut deals with drug makers was unthinkable. Democrats have been pushing for it since President Bill Clinton proposed his contentious health care overhaul in 1993. The pharmaceutical industry’s fierce lobbying against it has become Washington lore.

“This is like lifting a curse,” Senator Ron Wyden, Democrat of Oregon and the architect of the measure, said of the Medicare negotiation provision. “Big Pharma has been protecting the ban on negotiation like it was the Holy Grail.”

David Mitchell, 72, is among those who would be helped. A retired Washington, D.C., public relations worker, he learned in 2010 that he had multiple myeloma, an incurable blood cancer. He pays $16,000 out of pocket each year for just one of four medicines he takes. He also founded an advocacy group, Patients for Affordable Drugs.

“Drugs don’t work if people can’t afford them, and too many people in this country can’t afford them,” Mr. Mitchell said. “Americans are angry and they’re being taken advantage of. They know it.”

Still, the measure would not deliver every tool that Democrats would like for reining in prescription drug costs. The negotiated prices would not go into effect until 2026, and even then would apply only to a small fraction of the prescription drugs taken by Medicare beneficiaries. Pharmaceutical companies would still be able to charge Medicare high prices for new drugs.

That is a disappointment to the progressive wing of the party; The American Prospect, a liberal magazine, has dismissed the measure as “exceedingly modest.”

Prescription drug prices in the United States are far higher than those in other countries. A 2021 report from the RAND Corporation found that drug prices in this country were more than seven times as high as in Turkey, for instance.

The pharmaceutical industry spends far more than any other sector to advance its interests in Washington. Since 1998, it has spent $5.2 billion on lobbying, according to Open Secrets, which tracks money in politics. The insurance industry, the next biggest spender, has spent $3.3 billion. Drug makers spread their money around, giving to Democrats and Republicans in roughly equal amounts.

At a media briefing last week, Stephen J. Ubl, the chief executive of PhRMA, the drug industry’s main lobbying group, warned that the bill would reverse progress on the treatment front, especially in cancer care — a high priority for Mr. Biden, whose son died of a brain tumor.

“Democrats are about to make a historic mistake that will devastate patients desperate for new cures,” Mr. Ubl said, adding, “Fewer new medicines is a steep price to pay for a bill that doesn’t do enough to make medicines more affordable.”

But Dr. Aaron S. Kesselheim, a professor of medicine at Harvard Medical School and Brigham and Women’s Hospital, said he believed the measure would spur innovation, by “encouraging investment in important new products rather than encouraging pharmaceutical companies to try to keep pushing the same product and delaying generic entry as long as possible.”

In 1999, after his health care plan failed, Mr. Clinton resurrected the idea of Medicare prescription drug coverage. But this time, instead of proposing that Medicare negotiate with companies, he suggested leaving that to the private sector.

“At that point, what we were trying to do was to accommodate the recognition that Republicans were lockstep in opposition to any type of government role,” said Tom Daschle, the former Senate Democratic leader.

But it took a Republican president, George W. Bush, and a Republican Congress to push the prescription drug benefit over the finish line.

Medicare Part D, as the benefit is known, had the backing of the drug industry for two reasons: The companies became convinced that they would gain millions of new customers, and the bill contained a “noninterference clause,” which explicitly barred Medicare from negotiating directly with drug makers. Repealing that clause is at the heart of the current legislation.

The architect of the benefit was a colorful Louisiana Republican congressman, Billy Tauzin, who led the House Energy and Commerce Committee at the time. In Washington, Mr. Tauzin is best remembered as an example of the drug industry’s influence: He left Congress in January 2005 to run PhRMA, drawing accusations that he was being rewarded for doing the companies’ bidding — an accusation Mr. Tauzin insists is a false “narrative” created by Democrats to paint Republicans as corrupt.

Joel White, a Republican health policy consultant who helped write the 2003 law that created Medicare Part D, said the program was designed for private insurers, pharmacy benefit managers and companies that already negotiate rebates for Medicare plan sponsors to use their leverage to drive down prices.

“The whole model was designed to promote private competition,” he said.

In the years since Medicare Part D was introduced, polling has consistently found that a vast majority of Americans from both parties want the federal government to be allowed to negotiate drug prices. Former President Donald J. Trump embraced the idea, though only during his campaign.

The new legislation targets widely used drugs during a specific phase of their existence — when they have been on the market for a number of years but still lack generic competition. The industry has come under criticism for deploying strategies to extend the patent period, like slightly tweaking drug formulas or reaching “pay for delay” deals with rival manufacturers to postpone the arrival of cheap generics and “biosimilars,” as the generic versions of biotechnology drugs are called.

The drug maker AbbVie, for instance, piled up new patents to maintain a monopoly on its blockbuster anti-inflammatory medicine Humira — and it has reaped roughly $20 billion a year from the drug since its main patent expired in 2016.

Ten drugs would qualify for negotiation in 2026, with more added in subsequent years. The bill outlines criteria by which the drugs would be chosen, but the ultimate decision would rest with the health secretary — a provision that Mr. White, the Republican consultant, warned would lead to “an incredible lobbying campaign” to get drugs on the list or keep them off it.

Analysts say the bill would hurt drug makers’ bottom lines. Analysts at the investment bank RBC Capital Markets estimated that most companies affected by the measure would bring in 10 to 15 percent less revenue annually by the end of the decade.

But while PhRMA has warned that a decline in revenue will make drug makers less willing to invest in research and development, the Congressional Budget Office projected that only 15 fewer drugs would reach the market over the next 30 years, out of an estimated 1,300 expected in that time.

The Senate is expected to take up the bill as early as Saturday, then send it to the House. If it passes, as expected, it will pierce the drug industry’s aura of power in Washington, opening the door for more drugs to become subject to negotiations, said Leslie Dach, founder of Protect Our Care, an advocacy group.

“Once you lose your invincibility,” he said, “it’s a lot easier for people to take the next step.”

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The Best Fashion Instagrams of the Week: Zendaya, the Biebers, Kendall Jenner, and More

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Among the many things we gave thanks for on Thursday are the best fashion instagrams of the week. We’re mostly kidding, but there were some stellar looks these past seven days. First up, was sun-drenched Zendaya, who posed in a sand-colored cropped cardi in front of, well, a dune. Perhaps, she is on the set of…Dune

Justin and Hailey Bieber headed to Japan to celebrate Mrs. Bieber’s birthday. The duo were dressed in their coziest clothes: Justin opted for a pale yellow sweatsuit with a beanie and hulking chain, while Hailey wore an oversized collar shirt with sweats. While it’s not a high fashion moment, we did learn that Justin has a cute nickname for his wife thanks to his love-packed caption: “bum bum”.

Kendall Jenner went the less clothed route in an outré way. Taking a mirror selfie, she wore a cozy black sweater, but in lieu of pants or a skirt, the model opted for a pair of black tights. An even bolder moment? Jenner stepped out in the look, which was captured by paparazzi. 

Finally, Devon Lee Carlson is putting her twist on the latest suiting craze. The phone case influencer wore a super polished ’90s-era suit with a cubicle-ready belt, but with a tiny playful colorful graphic T-shirt and red sneakers for a casual touch. Hire us, Carlson! 

Here, see the best fashion Instagrams of the week. 

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American Rituals

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Abiquiú, New Mexico

At the Monastery of Christ in the Desert, a remote abbey beside the Chama River in northern New Mexico, some two dozen Benedictine monks begin their days in darkness.

At 3:30 a.m. one Sunday this past winter, a bell summoned the monks to vigils, the night prayer. Under a clear sky full of stars, they made their way in silence from their cloister cells to an adobe chapel. Seated in wooden pews, the brothers, most in black habits, began chanting the first of 12 psalms. They used the ancient Gregorian melody, but with English words: “O Lord, open my lips, and my mouth shall proclaim your praise.”

The sky was still dark when a second bell rang, just before 6, calling the monks to the dawn prayer, lauds. Back in the chapel, now wearing white cowls over their habits, they chanted again. As they began Psalm 150 — “Praise God in his holy place” — the tall windows above the sanctuary turned from black to midnight blue, the first hint of daybreak.

The sun rose over the next hour, illuminating the chapel’s backdrop — the Mesa de las Viejas, whose 500-foot rock walls faded from red to shades of sand and cream in a glowing gradient. Save for the faint rush of the Chama River, a sage green tributary of the Rio Grande, the canyon was soundless.

The setting was carefully chosen. The Rev. Aelred Wall, who founded the monastery in 1964, had scoured the country for a spot where he and his brother monks could “return to the sources” — to the quiet and isolation necessary for their contemplative vocation. Passing through New Mexico, he heard about an old ranch house for sale 75 miles northwest of Santa Fe — 115 acres along the Chama, surrounded by national forest.




The adobe chapel of the Monastery of Christ in the Desert.

Father Wall found the property at the end of a 13-mile dirt road. He sent an ecstatic letter to his friends at the Mount Saviour Monastery in Elmira, N.Y., waxing poetic about the river valley and its “great sentinels” of colorful cliffs. “Then came the cathedrals in stone, some of them Romanesque, some of them Gothic,” he wrote.

Father Wall bought the ranch house. He asked his friend George Nakashima, the master woodworker and architect, to design a chapel.

The chapel was built of adobe in the shape of a Greek cross, with arms of equal length, using clay from the site. Hand-carved doors were brought from Mexico, the bell from an old church in the northern New Mexican village of Questa. The artist Ben Shahn, a friend of Mr. Nakashima’s, contributed two large stained-glass windows. Georgia O’Keeffe, who lived 25 miles away, in Abiquiu, served as an artistic consultant.

Set against the towering cliffs, the adobe chapel looks otherworldly. The Cistercian monk and writer Thomas Merton, who visited the monastery in 1968, once likened its bell tower to “a watchman looking for something or someone of whom it does not speak.”

Shortly after 9 a.m., the bell rang again, for Mass. About 20 visitors settled into chairs in the back of the chapel. Abbot Christian Leisy, in purple vestments, walked around the altar, swinging a thurible of smoldering incense. Smoke swirled and billowed in the light as it rose.




The Tabernacle in the Abbey Church.



Brother Bede in the Cloister.



Brother Chrysostom held a rosary.

A monk read from the Book of Baruch: “Take off your robe of mourning and misery; put on the splendor of glory from God forever.” The second reading was from Paul’s letter to the Philippians. The Gospel was from the third chapter of Luke, in which John calls on the people of Judea to repent and be baptized and “prepare the way of the Lord.”

Abbot Christian’s homily noted that the first lines of the Gospel situated us in history — “the 15th year of the reign of Tiberius Caesar, when Pontius Pilate was governor of Judea.” Luke, he said, wants us to understand that these events really happened. The passage is also a reminder that God often surprises. God intervenes on the margins, speaking not through Caesar or Pontius Pilate, but through John — “someone unknown, someone living in the desert, eating wild honey and insects.”

Abbot Christian closed by reading a Jewish folk tale from the philosopher Martin Buber. It told of a Rabbi Eisik, in Krakow, who dreams three times that someone suggests he look for treasure under a bridge in Prague. The rabbi travels to Prague, only to learn that the treasure was at home, buried under his stove.

After Mass, most of the monks retreated to private quarters. A boisterous group from the Washington National Cathedral migrated over to the gift shop and loaded up on wares made by the brothers: goat-milk soap; scented candles; their latest album of Gregorian chant, “Blessings, Peace, and Harmony.”

Shortly after 11 a.m. the bell rang again, calling the monks. As the visitors drove off in a caravan, sending dust clouds into the blue sky, the brothers filed back into the chapel. — Abby Aguirre




The Monastic Cemetery near the chapel.

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Sweating Through a Honeymoon in Paradise

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Listen. I can be laid back when I have to be. I have been known to wait five or six hours before answering the occasional email. I have at times neglected to shake a towel vigorously before using it, risking unknown vermin latching onto my vulnerable, naked body. So when my husband and I decide to honeymoon in Bali, I have faith I will be able to enjoy it. To appreciate the views of unadulterated nature as I drift up and down a luxurious hotel infinity pool. And not necessarily think about, say, what kind of exotic parasites might potentially be inserting themselves into my vagina within said infinity pool.

At some point, perhaps basking in the glow of our travel agent’s enthusiasm, I must have decided my rampant O.C.D. wouldn’t be able to follow me to Bali, through interminable customs lines and sprawling opulent resorts and into the river-facing hotel spa where the woman in charge of my three-and-a-half-hour massage is now telling me to relax.

A three-and-a-half-hour massage is long. Longer than James Cameron’s “Titanic.” As the masseuse cakes my back with mud, I wonder what would be happening right now in “Titanic” if I had started it at the same time as this massage. Would Jack be learning to use utensils yet? Or would the ship be filling up with water already and I can break free sooner than I thought because time stops still here and in fact all notion of time as I know it has changed, and I will now understand time as a circle like Amy Adams’s character in “Arrival”?

“Relax,” the masseuse whispers as she applies pressure to my very tense neck, and I try not to think about the mysterious animal feces I found on the floor of our bungalow last night which my husband, in a bout of self-preservation, attempted to convince me were just a bit of rubble.

After the massage, in an attempt to relax further, I scan our bedroom floor with the iPhone flashlight because the lighting in the room is elegantly dim and by elegantly I mean frustratingly for someone who is not planning to engage in seduction at any point during this trip. I look up different critter feces on Google. I conclude the ones dotting our bungalow floor are salamander feces.

“Salamanders are great!” my mom gushes over our WhatsApp call, which I have initiated in a whispered panic from the locked bathroom so my husband won’t accuse me of failing to enjoy our honeymoon.

The smart toilet keeps greeting me, its lid opening and closing with a little whir, confused as to why I’m not using it.

“Salamanders eat all the bugs! They’re there to help you!” my mom says with forceful enthusiasm.

I do not ask her what if a salamander’s feces drops from the ceiling into my mouth because I’ve noticed her patience run short with this type of question over the years.

In the morning I am awakened by what I assume are ambulances but which are allegedly cicadas. My left ankle is swollen with two mosquito bites. I suffer from “skeeter syndrome,” which means mosquito bites on my skin distend to tumoral degrees and erupt in tiny welts. So the salamanders are clearly not doing their job, or: there are so many mosquitoes in this room their predators are sated and unable to eat them all — a frightening prospect.

I casually let this information drop as our concierge drives us through the resort in a buggy, a frangipani flower tucked behind his ear. He promises to fix the bug problem and drops us off at the lobby. A car is taking us to a traditional Balinese dance at a nearby temple. It is on a cliff top with scenic views of the Indian Ocean and sheathed in what the internet calls a “peaceful ambience.”

According to my iPhone, there is 90 percent humidity during the outdoor dance. I presume 100 percent humidity involves drowning. Rivulets of sweat pour down my spine like caressing fingers. I spray DEET on myself so profusely I can taste the chemicals on my tongue through my nostrils. The sun sets and the temperature cools slightly. Then the dancers set the stone stage on fire.

Suddenly (to the tune of Wagner’s “Ride of the Valkyries,” in my head), swarms of moths the size of industrial pedestal fans descend from the heavens, slapping us in the face and alighting on our backs so that unacquainted audience members begin to pick them off one another in a display of solidarity. They’re just moths, relax, I repeat to myself, smiling emptily for my husband’s camera as the family seated behind me swat them off my shoulder blades.

Once the dance ends, our pores dilated from our impromptu steam bath, we make our way down the steep cliff to the parking lot, monkeys as big as dogs on either side of us, eyeing our purses and phones. One of them sits alarmingly close to our car. Our guide advises us to hide our jewelry and avoid eye contact.

When we return to the hotel, we find that a dramatic mosquito net has been swathed over the bed, and rubber has been stuffed into the window gaps. I DEET myself regardless. I trust no one.

On our last day in Bali my husband and I perform a Balinese wedding ceremony because it’s too late to cancel. The officiants warn us that they will sprinkle a little ceremonial water on us. We agree to this, and thus commences our soothing, spiritual journey. The priest proceeds to pour bowl after bowl of ceremonial water on our scalps. My makeup, hair and contact lenses stream down my cheeks. My eyes burn. I wonder if I could get a urinary tract infection this way. The priest sticks grains of rice to our dripping foreheads. They slide off and pellet our laps. The water never stops. It is more eternal than our love.

I count the hours until I return home. I berate myself for doing this, reminding myself this is the only trip of this scale I will ever take and as such it should be enjoyed.

On the two plane rides home I watch three “Bridget Jones” movies in a semi-catatonic state. I feel numb when we step into our apartment. I Google “Bali parasites you have to extract with tweezers from eyeballs weeks later.” The results are inconclusive. I start to relax. Then I notice them. Crawling up our kitchen walls. Pantry moth larvae. I cry a little bit. My husband cries a little bit. I miss Bali.

Episode is a column of first-person essays exploring a moment in a writer’s life. Virginia Feito is the author of the novel “Mrs. March” and a writer for Vanity Fair Spain. She lives in Madrid.

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