PDABs and the Threat to Healthy Aging, Innovation, and Health Equity
by Michael Hodin
Recently, a study across the United States found that 1 in 5 adults over the age of 65 either skipped, delayed, took less medication than prescribed, or used another person’s prescription due to concerns about cost — a jump from 1 in 7 older adults in 2016.[1],[2] This poses significant concerns across several dimensions: worsened individual health as well as population health, and also increased burden to healthcare systems resulting from more frequent doctor visits, hospitalizations, or the need for more expensive interventions. As it stands, much of the longevity that we enjoy today has been enabled through our access to increasing numbers of increasingly effective medicines — but this is at risk if access is cut.
As patients across the country grapple with the costly burden of healthcare, there is a growing presence of legislation at the state level to create or expand entities to address the high out-of-pocket costs that patients face when accessing healthcare treatments and services. One such entity, a prescription drug affordability board — or a PDAB — is a state government-appointed board that has the authority to review prescription drug costs and determine if they present an affordability challenge for patients. Many established or proposed PDABs are given a singular tool to leverage in efforts to address patient costs — an upper payment limit (UPL). A UPL is a ceiling amount that healthcare payers, such as state Medicaid programs and commercial insurers, can reimburse for the purchase of a medication that a PDAB deems to be unaffordable. While PDABs and the goal of lowering prescription drug costs can sound promising, the use of UPLs may undercut its own intention: threatening our ability to reach the populations most in need with breakthrough treatments and could exacerbate existing health disparities.
In February 2024, our Executive Director at GCOA, Melissa Gong Mitchell, participated in a webinar panel discussion hosted by the National Minority Quality Forum (NMQF) to discuss the impact of state PDABs and other price setting policies on quality of care, patient access to medications, and health equity. In addition to NMQF, Melissa was joined by experts from Community Access National Network (CANN) and the National Black Caucus of State Legislators (NBCSL) to discuss the current landscape on PDABs as more states consider the implementation of these boards to address drug costs.
“When you’re doing something for the community, you have to be doing something with the community — on the [PDABs] and passing of legislation, if you don’t have community involved and meeting them where they are at, we won’t all understand what is at stake and the overall impact to our health care access needs.” (Melissa Gong Mitchell | Global Coalition on Aging (GCOA))
The panel’s conversation underscored that to ensure that everyone — regardless of age, race, or economic status — has the potential to age healthily, we cannot stop researching and bringing to market innovative treatments. This perspective has been central to GCOA’s vision of healthy longevity — and it is because of this that we launched the Alliance for Health Innovation in 2022 to ensure that our society can build upon advancements in longevity through continued innovation.
As one example, Colorado’s state PDAB is the most developed, already in the process of completing an affordability review for one of the first five drugs selected to undergo that assessment. Several of the drugs selected for review by the Colorado Board are used to treat conditions for which risk grows as we age — the very drugs that are keeping us healthier, working, and in society for longer. When we assess the value and cost of a drug, we must consider not only the benefits to individuals, but also the system and overall costs incurred in the future. With systemwide patient and financial impacts at stake, PDABs must consider the use of tools beyond a UPL to ensure that they are not compounding disparities and limiting access to new innovations.
We encourage you to watch the full recording of the recent NMQF webinar and learn more about the impact of state PDABs on efforts to advance healthy aging equity.
Our country is at an important juncture. According to the 2020 Census, the U.S. population aged 65 and over grew nearly five times faster than the total population over the 100 years from 1920 to 2020. Healthcare reforms must address this shift in population demographics to reflect the needs of an aging society. However, jeopardizing healthy aging through harmful policies at the state and federal levels that endanger the very innovation that made these advancements possible is the wrong approach. We must make innovations an accessible reality for the people who need them most, not stamp out those efforts before they have begun.
Read the letter that GCOA sent to the Colorado PDAB outlining concerns around the Board’s impact on treatment access, health equity, and healthy aging.
[1] https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2805012
