Nearly five years ago, the nation’s leading group of obstetricians and gynecologists issued a policy statement saying the time had come for oral contraception to be available without a prescription.

We wrote about it and everything.

In the intervening years, some states have changed their laws. California authorized pharmacists to distribute most types of hormonal birth control. Oregon passed a similar law covering both pills and patches.

But neither law changed the status of birth control pills from prescription to over-the-counter. Only the Food and Drug Administration can do that. And in Oregon’s case, the law does not apply to people of all ages. People under 18 are still required to get their first contraceptive prescription from a doctor.

But researchers say there is no evidence that adolescents are at greater risk from birth control pills than adult women.

A review of oral contraceptive research presents the most comprehensive evidence yet that, as the authors state, “There is no scientific rationale for limiting access to a future over-the-counter oral contraceptive product by age.”

“There is a growing body of evidence that the safety risks are low and benefits are large,” says Krishna Upadhya, an assistant professor of pediatrics at the Johns Hopkins University School of Medicine and the lead author of the review, which was published this week in the Journal of Adolescent Health.

In fact, she says, some of the potential negative side effects of oral contraception are less likely in younger people. For example, birth control pills that contain both estrogen and progestin come with an increased risk of a type of blood clot called a venous thromboembolism, but that risk is lower in teenagers than in older women.

As a result, the pill is “potentially safer the younger you are,” says Upadhya.

The review also found no evidence that increased access to birth control would lead teenagers to have more sex or engage in riskier sex, a concern voiced by some critics of oral contraception access.

Teen pregnancy rates are way down in the U.S., and teenagers are using contraceptives more often. Between 2007 and 2013, the number of 15 to 19-year-olds giving birth dropped 36 percent. The abortion rate has also fallen.

“These pills are safe and effective and we should reduce barriers to using them. And teens should benefit just as adult women do,” Upadhya says.

One reason more girls and women are using birth control is that the Affordable Care Act requires insurers to fully cover prescribed contraception. That includes the pill, implanted hormonal birth control and intrauterine devices.

So what would happen if oral contraception no longer required a prescription? The Affordable Care Act does not require insurance companies to cover over-the-counter birth control like condoms, sponges and spermicide. If hormonal birth control was available over the counter, it too would fall outside the law’s coverage mandate.

Sen. Patty Murray, D-Wash., introduced a bill in 2015 that would automatically amend the language of the ACA to require insurance companies to pay for any contraceptive approved for over-the-counter sale by the FDA. Sen. Kelly Ayotte, R-N.H., introduced a separate bill that proposed giving priority to any request from a birth control manufacturer asking the FDA to consider over-the-counter status for its drug, as long as it only applied to women over 18. Neither bill has made it out of committee.

The current Republican proposal to repeal part of the ACA would not affect mandatory coverage for prescription contraceptives, as we have reported.

The American College of Obstetricians and Gynecologists has issued multiple statements in the past year stressing that, while the group still supports making oral contraception available without a prescription to teens as well as adults, such a change is not enough on its own for making birth control available to everyone who needs it.

“Over-the-counter contraception is not an acceptable substitute for the ACA contraceptive coverage mandate,” the group wrote in a statement issued in February.

Of course, there is currently no version of the pill has been approved by the FDA for use without a prescription.

An FDA spokesperson said the agency “generally cannot confirm or deny the existence of a pending product application,” so it is difficult to know whether any birth control manufacturers have requested that that their products be considered for over-the-counter status.

If a manufacturer did apply, the FDA would consider many of the same things Upadhya and her team looked at, including safety and efficacy data and potential age restrictions.

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Rising drug prices are one of the biggest challenges in health care in the United States. More people are using prescription drugs on a regular basis, and the costs of specialty drugs are rising faster than inflation.

President Donald Trump has promised over and over again to drive down drug prices.

Just last week on Twitter he wrote: “I am working on a new system where there will be competition in the Drug Industry. Pricing for the American people will come way down!”

But Trump already has a weapon he could deploy to cut the prices of at least some expensive medications.

That weapon is called “march-in rights.”

Here’s how it works. When the federal government — through an agency like the National Institutes of Health — pays for medical research that leads to an invention that can be patented, federal law gives the government a license to use that intellectual property.

Rep. Lloyd Doggett, a Texas Democrat, wants the U.S. to exercise those rights to force down drug prices.

“I believe that when taxpayers finance research that produces a pharmaceutical, they have an interest in being able to afford that pharmaceutical, and that’s not happening now,” Doggett told Shots.

What is happening is that the government pays for the research and the doctors and companies market the medications. The government retains a license to the intellectual property as a check, to ensure that the medicines are available to the public on “reasonable terms.”

But, Doggett said, the government has never used its march-in authority.

“Millions of dollars go out and federal research dollars; pharmaceuticals result, and then they get priced at such outrageous levels,” Doggett said. “They’re so high that some people cannot afford them.”

Last year Doggett, along with 50 other members of Congress, backed a request by the group Knowledge Ecology International for NIH to use its march-in authority to lower the price of Xtandi , a prostate cancer drug.

At the time the medication was sold by a Japanese company for about $88 a pill, according to KEI, a nonprofit organization that advocates for social justice. Last April, KEI said, a Canadian drug company offered to sell a generic version of Xtandi to the government for just $3 per pill.

NIH declined to use its license or take that offer.

Doggett and KEI appealed to former Health and Human Services Secretary Sylvia Burwell, who declined to overrule the NIH.

Doggett then asked HHS to simply hold hearings, and lay out guidelines for when it might consider exercising march-in rights in response to price gouging. Again, the agency refused.

Burwell said march-in authority is only allowed if certain criteria are met, “such as alleviating health or safety needs, or when effective steps are not being taken to achieve practical application of the inventions.”

She said the agency considered, in 2004, whether high prices meet those criteria and determined they do not. In that case the agency was looking at expensive drugs to treat HIV and AIDS.

“The attitude there seems to be, ‘We’re not in the pricing business, we’re only in the research business and we’re not too interested in getting into the pricing business,’ ” Doggett said.

But Dr. Aaron Kesselheim, an associate professor of medicine at Harvard Medical School who studies intellectual property law and drug development, thinks the agency should be interested.

“When you think of the phrase ‘reasonable terms’ — reasonable terms inherently means, I think, the price that a drug is available for,” he told Shots.

If the Trump administration decided to go that route, Kesselheim said, it could use its license to contract with a generic pharmaceutical manufacturer to make the drugs at a lower price. Or it could, potentially, take that license and buy the medications from a foreign drug maker.

A radical move like that could have an effect on drug prices across the board, said Sara Fisher Ellison, an economist at MIT.

“Definitely an unusual action like that could have spillover effects on the drug prices of other companies,” she said, “because obviously they might see themselves as the next potential target, and might want to make themselves a less attractive target by lowering their prices.”

But those lower prices could also make drug companies less eager to invest lots of money in new medications.

That’s the trade-off the government has always had to wrestle with. But it’s one Trump could very well decide is worthwhile.

“Perhaps we as a country would rather have lower drug prices and a little less innovation,” Ellison said.

Doggett hopes Trump might just take that deal.

“This is something where President Trump, if he wants to fulfill a campaign promise, can take action that the last administration refused to take in order to protect consumers,” Doggett said.

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Dr. Amin Rabiei knew he wanted to work in medicine from an early age. When he was growing up in Iran, he watched his dad experience seizures and his mom struggle to help. Rabiei went on to medical school in Iran, then practiced at a rural clinic there, all the while working toward an important career point that culminates Friday: Getting matched to a medical residency training program in the United States.

“I decided to come here to have better opportunities for research and clinical education,” says Rabiei, who is already in Philadelphia on a research visa doing postdoctoral research at Thomas Jefferson University. His ultimate aim? “Hopefully to share this information and these skills for the people who need this in the undeveloped countries.”

Rabiei hopes to train in neurology with a focus on epilepsy. For international medical graduates like him, becoming eligible for residency training in the U.S. is a rigorous process that can take years of planning, financing and work. In general, landing one of these coveted spots, a requirement for anyone aspiring to train and practice medicine in the U.S., is already competitive; about 32,000 slots are available to an applicant pool of 42,000. Last year, about half the applicants from outside the U.S. were successful in getting a match.

But now, as Rabiei braces for the day when these decisions are released, he and others worry that the recent White House executive orders on immigration have further diminished their chances of getting a match.

“It becomes like double stress,” Rabiei says.

“It is a valid concern,” says Dr. William Pinsky, president of the Educational Commission for Foreign Medical Graduates.

Pinsky says President Trump’s executive orders have created new unknowns in the visa process for foreign medical graduates — and the ambiguity puts the residency programs, as well as the applicants, in a bind. Though the training programs rank applicants according to their merits and qualifications, the matching system hinges on these young doctors being available and ready to start caring for patients in July. Many residency programs can’t risk having an empty seat because of visa processing delays.

“Program directors have to weigh various factors of applicants, from their medical knowledge, ability to communicate, their observed level of empathy, their leadership capabilities — and their ability to be available when July 1 comes,” Pinsky says.

He estimates that roughly 300 to 400 applicants this year from the countries covered by the White House executive orders would now need to apply for a visa — or change or renew the one they have — to train in the U.S.

“I have talked to a few program directors that were probably going to rank individuals from these countries lower on their preference order than they would have otherwise,” Pinsky says.

About 1800 people from these countries are already in medical residencies in the United States.

Further complicating this year’s “match week,” most residency programs ranked their preferences of applicants on February 22 — in between the issuing of the first and second executive orders on travel restrictions. Those match decisions are to be released Friday, March 17.

“The timing and uncertainty of the executive order could not have come at a worse time,” Pinsky says.

The first White House executive order restricting travel came out in January and applied to seven Muslim majority countries: Iran, Iraq, Libya, Somalia, Sudan, Syria and Yemen. The more recent version, announced in early March, removed Iraq from the list. It bans new visas from the remaining six countries for 90 days, but also includes some exceptions that allowU.S. entry — such as for lawful permanent residents of the U.S. and those with other valid documents.

The Educational Commission for Foreign Medical Graduates, which is based in Philadelphia, is responsible for certifying all international graduates who wish to apply for residency and practice medicine in the U.S. This involves administering qualifying exams and overseeing other background checks. ECFMG is also closely involved in the visa process, as a main sponsor of J-1 clinical visas for international graduates — the most common type of visa granted for training and practicing medicine in the United States. A smaller number of institutions may directly sponsor residents through an H-1B visa.

“If someone has a visa, as I understand, even though they’re from one of these six countries, it’s not an issue,” Pinsky says.

Even so, it’s still unclear who is eligible to get a visa or how long it will take. His organization is awaiting clarification from the federal government on that process and whether, as before, the process can be expedited in order to be completed by the start of a medical residency.

Dr. Atul Grover, vice president of the Association of American Medical Colleges, says large residency programs may be less affected by the executive orders than small ones.

“I think our bigger institutions, like Penn and CHOP [Children’s Hospital of Philadelphia], have very much said, ‘Just on principle we’re going to rank these people if we think these are the best people,’ ” Grover says.

“You know, if I’m Penn and I’ve got an internal medicine class of like 45 residents, maybe I can take more of a chance. If one resident doesn’t come maybe I can figure it out.” (Indeed, a spokesperson from Penn tells Shots they don’t think the executive order will impact the institution’s ability to train residents who match there.)

But waiting for somebody’s visa to come through can be a greater risk for smaller programs, Grover says. “You can’t afford to lose 10 or 25 percent of your class. It’d be a big gamble for them.”

Dr. Robert Wimmer heads a small pediatric residency program at Einstein Medical Center in North Philadelphia, and says about half the residents there are medical graduates from another country. The program can’t afford to accept someone in their new class of 10 if there’s a chance they might not be able to start in July because of visa issues.

“It’s unfortunate,” Wimmer says. “Many work their tails off to get to the U.S. We might be losing a lot of talent.”

While the United States has long been known as an epicenter for top medical research and care, Pinsky worries that reputation and the whole system could suffer if an uncertain immigration climate discourages young doctors from trying to train and practice in the United States.

“There could be an issue of access to health care as well as a quality situation,” he says.

Rabiei says he and his Iranian peers are trying to stay positive.

They feel encouraged by the support they’ve received from colleagues and their universities.

“When you try so hard to get to your dream, and all of a sudden you feel that there are some issues — unexpected problems — it’s a really bad feeling,” he says.

Rabei won’t know until Friday exactly where he’ll be a medical resident, but he was thrilled to learn Monday that he has been offered a position by at least one institution. He knows other Iranians who were not so lucky.

This story is part of NPR’s reporting partnership with WHYY’s The Pulse and Kaiser Health News.

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When Democrats held a majority of the seats in the U.S. House of Representatives, and Rep. Nancy Pelosi was the house speaker, she helped pass the Affordable Care Act, also known as Obamacare.

Now, after more than six years in the minority party, she’s watching House Republicans move to repeal and replace parts of the law.

She says that although Democrats don’t have the votes to stop the GOP legislation alone, they can still show their opposition to it.

“In my office I have a painting of Abraham Lincoln, who said, ‘Public sentiment is everything’,” Pelosi told NPR’s Robert Siegel. “Regardless of the number of Democrats in the House, the number of people who are affected, 24 million [people] who would lose their care, I’m depending on public opinion. … The fact is the more we point out the shortcomings of the legislation, the fewer votes [Republicans] will have.”

The interview below has been edited for length and clarity.

Interview Highlights

On the shortcomings of the Affordable Care Act

Let’s go back to where we were before the Affordable Care Act, because that was a time where [some people] wouldn’t even be able to have any insurance. So what was the purpose of the Affordable Care Act? [It was] threefold. One, to lower cost. Two, to improve benefits. And three, to expand access for millions more people. And it’s done all three.

…

Look, there hasn’t been a bill ever passed of this magnitude, whether it was social security, Medicare, Medicaid, voting rights, civil rights bill, that was not revisited. Some of the improvements we [could] have [had] in the Affordable Care Act were there, but the Republicans prevented them from happening. So you can be a self-fulfilling prophecy and say, “I’m gonna make sure this doesn’t work now. Now see, it didn’t work.”

On whether the Democrats could work with President Trump or House Speaker Ryan on health care legislation

We have a responsibility to the American people to find as much common ground as we can. There has to be sincerity, though. … I don’t think he has the faintest idea — the president — about the health care thing.

[But Rep. Paul] Ryan … is [a] philosophical, right-wing, anti-government [person], and so an act of mercy for him is to reduce the government’s role. So we’re talking about two different things. They’re debating whether it’s “Trumpcare” or “Ryancare,” but neither of them wants it identified with themselves because it’s such a failure in the public mind.

On President Trump’s knowledge of health care

The more the president might learn about [health care] then he might see where there’s a path [to working with Democrats], because to tell you the truth, the Affordable Care Act is a private-sector initiative. It contains many Republican ideas.

Understand this about Republicans, and then you’ll understand part of what our challenge is here. They always are gearing whatever they do to benefit the high end. This is the biggest transfer of wealth in the history of our country, in terms of hundreds of billions of dollars going into the pockets of the top one percent of the people in our country, at the expense of the good health of our middle class and those who aspire to the middle class.

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Michael Botticelli served as President Obama’s director of National Drug Control Policy, and pushed Congress to pass a funding measure last year making more money available for the treatment of opioid addiction.

Now he’s concerned that the proposed Republican health plan will reduce access to health services for people with addiction.

“We know that people with addiction, and particularly in the opioid epidemic, need access to high quality health care in general,” Botticelli told NPR.

“We know that many people who are injecting drugs have viral hepatitis. We’ve seen outbreaks in parts of the country with people with HIV. … People need access to high-quality, comprehensive health care if they’re really going to deal with these issues.”

Botticelli discussed access to addiction treatment with NPR’s Robert Siegel, including how the proposed Republican health plan differs from the approach taken by the Obama administration and the broad societal effects of widespread opioid abuse. The interview has been edited for length and clarity.

Interview Highlights

On historically sparse coverage of addiction treatment

We knew going into the Obama administration that, historically, only a small percentage of people were able to access [addiction] care in the United States, about 10 percent, largely based on their inability to pay, not having insurance coverage, or having insurance coverage that didn’t cover addiction treatment services. So a large part not only of the Affordable Care Act but of our work with Congress was to pass the President’s budget proposal to give states and local [governments] additional resources for this.

On the societal cost of addiction

I would say we all pay the price for untreated addiction. Certainly we know that it raises health care costs. We know that untreated addiction actually has other costs to it, associated with crime and prison costs, that drive up our taxes. We have seen what historically has been a bipartisan effort to really use addiction treatment to make sure that we’re not filling our jails and prisons with people. So we’re all paying the cost for this.

Given the magnitude of this issue, I’ve been hard-pressed to find a family that hasn’t been impacted by addiction and particularly the opioid epidemic.

On Congressional support for addiction treatment funding

We had a tremendous amount of bipartisan support. Every member of Congress understands the impact that addiction, and particularly the opioid epidemic, has been having on their communities. Then-candidate Trump certainly heard this on the campaign trail, and quite honestly promised access to treatment as one of the prime strategies. So it’s… perplexing to me that members of Congress who support this [proposed health care] bill know the devastating effect that not having, and ratcheting back, addiction coverage is going to have, particularly for people in their districts.

On the potential effects of decreased access to addiction treatment

I think it’s not hyperbolic to forecast that we’re going to see dramatic increases in mortality associated with drug overdose deaths [if the proposed bill goes into effect.] I think we’re likely to see a significant impact on our emergency departments. Certainly we know crime rates go up with people with untreated addiction. … We know that untreated addiction has a nexus to homelessness. So the implications for this are profound, not only in terms of the mortality that we see with drug overdoses, but in health and human services and public safety systems.

On controlling the drug supply in the U.S.

Our approach to drug policy under the Obama administration really tried to strike this balance between supply and demand. In my interactions with the Mexican government, I made very clear that the United States has an obligation to reduce the demand for drugs, which we know will continue to prompt supply, but that the Mexican government had a responsibility as well to help us in this battle by reducing the supply, particularly of heroin and fentanyl that we see.

I have a lot of concerns in terms of the rhetoric that we hear now. Are we going to see the same of cooperation from the Mexican government to meet their obligations in this battle?

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NPR’s Audie Cornish talks to Rep. Kevin Brady, Republican of Texas and chair of the House Ways and Means Committee, about the GOP plan to repeal and replace the Affordable Care Act.

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The Republican health care bill would not affect Americans equally. Older, poorer people would see big reductions in coverage and cost increases, according to a report from the nonpartisan Congressional Budget Office. This first step in the GOP plan to repeal and replace the Affordable Care Act, also known as Obamacare, would also create a modest deficit reduction.

The report hands Democrats more ammunition in attacking the bill, while Republicans are divided: Some are playing defense, while others are backing away, and some are also proposing changes.

To see the potential impact of the bill as it stands, here are five charts, based on the CBO analysis.

Uninsured spikes immediately, then rises more slowly

First things first: The Republican health care bill would greatly ramp up the number of people who are uninsured. Currently, around 9.5 percent of Americans younger than 65 are uninsured. Under the Republican bill, the uninsured rate in 2026 would be nearly double that, at 18.6 percent, as opposed to the 10 percent it would be at under the Affordable Care Act.

Put into raw numbers, here’s how the growth in the number of uninsured looks: In 2018, the number of uninsured would be 14 million larger under the Republican bill than under Obamacare. In 2026, it would be 24 million larger.

That big upswing in 2018 would be largely attributed to repealing the penalties that came as a part of the individual mandate — not having a fine would lead lots of people to decide not to get insured. In addition, rising premiums would deter some from buying insurance.

In subsequent years, Medicaid changes would account for an increasing number of uninsured, eventually hitting 14 million. The rollback of the Affordable Care Act’s Medicaid expansion would begin in 2020, cutting the number of people on the program. In addition, no states would be able to take up the expansion in the future, further dropping the number of potential Medicaid enrollees.

Premiums go up, then down (but not for everyone)

The CBO’s report shows that premiums in the individual insurance market would increase first, then decrease, ending up 10 percent lower than they would be under the current law in 2026. That’s because young and healthy people would likely drop out early on, bringing premiums up. But the mix of people would eventually shift younger, pushing premiums down — younger people tend to be healthier, and therefore cost less to insure. In addition, insurers will not have the same requirements for sharing the cost of certain benefits.

Republicans are applauding this. In fact, Budget Director Mick Mulvaney said this week that while he (and others in the administration) are shrugging off the CBO’s findings as unreliable, this was one part of the report he believed:

“Everyplace else where the market is allowed to function, quality goes up and costs go down,” he said, “and I think if you look for something the CBO may have gotten right in this report, it’s that the premiums are actually going to come down in cost.”

But it wouldn’t work out the same for everyone. Many younger Americans would end up paying less, as would people young and old alike making middle-to-upper-middle incomes, according to the CBO analysis. However, premium costs would hit many low-income adults hard, particularly older low-income adults.

A 64-year-old making $26,500 would pay around $1,700 a month in premiums right now. Under the proposed changes, that person would pay $14,600, more than eight times more.

One big reason for that is that the new health care bill would change the gap between what young and old people will pay for their premiums. Currently, insurers can charge older enrollees three times what they charge someone younger. The Republican plan would up that from three-to-one to five-to-one.

Big leaps in the poor and uninsured

The uninsurance rate will increase among the poor and non-poor alike. But it appears it would grow the most — more than doubling — among older, low-income insurance buyers. Not coincidentally, that’s also the group that would see its cost of insurance climb in a huge way.

The uninsurance rate among people ages 50 to 64 who are below 200 percent of the federal poverty level would leap from 12 to 30 percent.

Smaller deficit

Under the Republican bill, the deficit would shrink by $337 billion over 10 years, or $33.7 billion per year on average.

That reduction would mainly come from the Medicaid rollback and, to a lesser degree, the end of Affordable Care Act subsidies. Both of those changes would reduce spending by a little more each year.

All told, Medicaid savings will come out to $880 billion over the decade. That reflects the massive changes that will be made to Medicaid under the plan. Existing enrollees could stay on, but the expanded income threshold that the Affordable Care Act set would move. That would mean fewer people could sign on in the future. Not only that, but the new plan would cap how much the federal government spends on Medicaid, making it much more expensive for states to keep up current levels of coverage.

A smaller deficit may make fiscal conservatives happy, but it’s altogether a modest shift. The deficit reduction here averages out to $33.7 billion per year. For comparison, the 2016 deficit was $587 billion.

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John Krahne received alarming news from his doctor last December. His brain tumors were stable, but his lung tumors had grown noticeably larger.

The doctor recommended a drug called Alecensa, which sells for more than $159,000 a year. Medicare would charge Krahne a $3,200 copay in December, then another $3,200 in January, as a new year of coverage kicked in.

For the first time since being diagnosed 10 years ago, Krahne, 65, decided to delay filling his prescription, hoping that his cancer wouldn’t take advantage of the lapse and wreak further havoc on his body.

With new cancer drugs commonly priced at $100,000 a year or more, Krahne’s story is becoming increasingly common. Hundreds of thousands of cancer patients are delaying care, cutting their pills in half or skipping drug treatment entirely, a Kaiser Health News examination shows.

One-quarter of all cancer patients chose not to fill a prescription due to cost, according to a 2013 study in The Oncologist. And about 20 percent filled only part of a prescription or took less than the prescribed amount. Given that more than 1.6 million Americans are likely to be diagnosed with cancer this year, that suggests 168,000 to 405,000 ration their own prescription use.

“Patients are being harmed daily” by high treatment costs, says Dr. Hagop Kantarjian, a leukemia specialist and professor at Houston’s MD Anderson Cancer Center. “It’s causing more deaths than necessary.”

For instance, one third of Medicare patients who were expected to use Gleevec — a lifesaving leukemia medication that costs up to $146,000 a year — failed to fill prescriptions within six months of diagnosis, according to a December study in the Journal of Clinical Oncology.

Stopping drugs like Gleevec could be cutting years from some patients’ lives. Instead of dying in five to seven years, patients with chronic myeloid leukemia who take Gleevec and similar drugs can survive nearly as long as people without cancer, and with a good quality of life, Kantarjian said.

Given that his lung cancer has grown slowly over the years, Krahne’s doctor thought it would be safe to wait until January to begin his new medication.

“We hope it doesn’t hurt my chance of cure,” says Krahne, from Santa Rosa, Calif. “It was an educated risk that we didn’t take lightly.”

Krahne made repeated calls to patient-assistance programs throughout January, trying to find help with his out-of-pocket costs. “The anxiety during those days or weeks was probably almost as bad as the day I was diagnosed with cancer,” Krahne says.

Doctors have a term for Krahne’s problem: “financial toxicity.”

“We’re talking about huge numbers of patients,” says Dr. Scott Ramsey, director of the Hutchinson Institute for Cancer Outcomes Research at the Fred Hutchinson Cancer Center in Seattle. “It’s an epidemic. And it’s not going away.”

Even patients with good insurance can face a financial crisis when trying to pay for cancer therapy. Medicare pays for the bulk of cancer care in the United States because 59 percent of cancer patients are older than 65. And although it covers a high percentage of the cost, copays for patients such as Krahne can easily reach $10,000 a year, according to Stacie Dusetzina, a researcher at the University of North Carolina who has found that privately insured patients with copays of just $53 were 70 percent more likely to stop taking Gleevec or take fewer doses than prescribed.

For Medicare Patients, No Ceiling On Copays

Unlike many commercial private plans, Medicare doesn’t set an upper limit on what patients pay out-of-pocket. Patients with chronic lymphocytic leukemia who begin oral medications this year, for example, can expect to have lifetime out-of-pocket costs of $57,000, according to a January study published in the Journal of Clinical Oncology.

High drug costs are a particular problem for the elderly, half of whom have $13,800 or less in available assets, and many have more than one expensive chronic condition, such as heart disease, diabetes or emphysema. The median income for people on Medicare was $24,150 in 2014, according to the Kaiser Family Foundation.

Medicare patients with cancer spend an average of 11 percent of their income on treatment, according to a November study in JAMA Oncology. Patients who don’t have supplemental insurance, which pays for treatment not covered by traditional Medicare, spend 23 percent of their income on cancer care. Ten percent of elderly patients without supplemental insurance spent 60 percent of their income on cancer expenses.

In John Krahne’s case, persistence finally paid off. After making repeated calls to patient-assistance programs in January, Alecensa’s manufacturer, Genentech, agreed to help pay Krahne’s out-of-pocket costs. He began taking the drug Jan. 27, six weeks after it was first prescribed.

It’s impossible to know whether Krahne’s health will be affected by the delay, said Ramsey.

“Most oncologists are OK with delays of up to a month, but after that they start getting anxious that further delays will harm chances for survival,” Ramsey says.

When thinking about having to find the money for more than $10,000 in cancer treatment a year, Krahne says: “Hopefully, I won’t have to do this year after year.”

Yet Krahne acknowledged that paying high prices is the cost of surviving cancer today. “So, hopefully, I will have to do this year after year.”

One New Drug Costs $1 Million A Year

While cancer has always posed a financial hardship for patients, the jaw-dropping costs of new cancer medications have led to widespread criticism of the pharmaceutical industry, on Capitol Hill and beyond.

List prices for oral cancer drugs doubled from 2011 to 2016, rising from an average of $20 for a day’s supply to $40, according to Express Scripts, a pharmacy benefit manager. Six of the 39 cancer drugs on the market in 2010 doubled or tripled in price by 2016; one quadrupled in price; one drug’s price increased eightfold.

Treating melanoma patients with the highest dose of Keytruda, an immune therapy that has led to long-term remissions in some patients, including former president Jimmy Carter, could cost more than $1 million a year.

Such costs are leading to soul-searching by doctors, who often struggle to help patients decide if drugs are worth the consequence of depleting their life savings, or going into debt or even bankruptcy.

“My job is to prescribe the best treatment,” says Dr. Yousuf Zafar, associate professor of medicine and public policy at the Duke Cancer Institute in North Carolina. “But I’m not doing my job if I prescribe a drug and walk away and leave them with tens of thousands of dollars in immediate debt.”

In a statement, the Pharmaceutical Research and Manufacturers of America, an industry group, noted that drug costs are only one part of the problem. “Many factors contribute to financial hardship for cancer patients … physician services, transportation expenses, and the inability to work, among other medical and non-medical factors, drive the cost burden on patients. We have also seen a rapid rise in the number of health plans with high deductibles for medicines.”

And officials at Gleevec’s manufacturer, Novartis, noted that the company provided financial aid to 130,000 patients last year, including those struggling to pay for Gleevec.

“We price our medicines to reflect the value they bring to patients and society,” says Novartis spokesman Eric Althoff. “We also continue to invest in new treatments so that we can find ways to make more cancers survivable.”

The Financial Pain Can Last For Years

The high cost of cancer medications can burden patients for years even after they finish treatment.

Liza Bernstein, 52, was diagnosed with breast cancer three times from 1994 to 2009. She emptied her savings account after her second diagnosis and gave up her apartment because she couldn’t pay her rent. Bernstein sold some belongings and put the rest in storage, where they remain. She has been living with friends and relatives ever since.

“People say ‘Call this foundation or that foundation,’ ” for help, says Bernstein, a freelance designer and patient advocate in Los Angeles who was unable to work for several years due to her illness. People don’t understand “the cognitive and emotional exhaustion of trying to manage this and wrap your brain around everything you need to do.”

Cancer often limits patients’ ability to hold down a job. Four years after diagnosis, one-third of previously employed breast cancer survivors were unemployed, according to a 2014 study. Patients who lose a job don’t just lose a paycheck; they often lose their health insurance.

In a 2012 study of 284 colorectal cancer patients, 38 percent reported one or more financial hardships as a result of treatment, such as being forced to sell or refinance their home or losing more than 20 percent of their income, even though nearly everyone in the study was insured. Seventeen percent borrowed money from family or friends, at an average of more than $14,000.

Twenty-three percent were in debt 20 months after their diagnosis, with an average debt of $26,860, according to the study. Even patients without severe hardship saw their fortunes change due to cancer, as they sold stocks and drew on savings.

About 3 percent of patients with cancer declare bankruptcy, says Ramsey, whose 2013 study found cancer patients are 2.7 times more likely to file for bankruptcy than those who’ve never been diagnosed.

Although Bernstein considered declaring bankruptcy, she said she couldn’t afford the $500 to $600 it would have cost for a lawyer and filing fees.

And bankruptcy isn’t just financially devastating.

Mortality rates among cancer patients who filed for bankruptcy are, on average, 79 percent higher than those of other patients, according to Ramsey’s 2016 study in the Journal of Clinical Oncology. Bankruptcy is associated with an especially high risk of death for certain cancers. For example, mortality rates are 2.5 times higher among patients with colorectal cancer who filed for bankruptcy compared with patients who didn’t file.

Financially stressed patients may skip pain medications and miss doctor’s appointments. And those who skip taking drugs to relieve nausea and vomiting, Ramsey said, can die from dehydration.

Finding Oneself In “A Place Of Need”

Some patients “have to choose between paying their meds and heating their home,” says Carla Tardif, chief executive officer at Family Reach, a New Jersey charity that provides financial aid to families dealing with cancer. “I went into a home and there were two sleeping bags on the kitchen floor. The mom said, ‘We sleep by the stove because I can’t afford the heat.’ “

Molly MacDonald, who was diagnosed with breast cancer at age 54, when she was a divorced single mother of five, opted not to undergo reconstructive surgery because of the cost. She worried about the increased risk of infection and hospitalization, which she knew she could not afford.

“All of my decisions were based on cost,” says MacDonald, of Beverly Hills, Mich. “We sold things. I cut the kids’ hair myself. Friends brought food. Then I found myself in line at the food bank. I used to have groceries delivered. It was interesting to find out how quickly someone can find themselves in a place of need.”

In October 2006, after MacDonald got back on her feet, she began soliciting donations for a nonprofit she created called The Pink Fund, which helps to pay breast cancer patients’ bills. The fund now pays about $65,000 in bills a month. “We’ve helped people who are living in storage units, living with their families, living in cars.”

MacDonald often draws from her experience when offering financial advice. Consider selling your house to prevent it from being taken away, she suggests. Remember that as bad as the situation is, it’s not permanent. But she also asks clients, “What in your house can you sell?”

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

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The proposed American Health Care Act targets the health provider Planned Parenthood with a set of proposed limits on Medicaid payments to the organization.

Monday, the nonpartisan Congressional Budget Office confirmed the magnitude of those limits. The Republican plan would block $178 million in Medicaid reimbursements to Planned Parenthood in 2017.

“The vast majority of our patients are on some kind of federal program,” Cecile Richards, president of Planned Parenthood, told NPR’s Ari Shapiro on Tuesday.

In all, she said, about 1.6 million patients receive health care from the organization each year through federal programs such as Medicaid, totaling upwards of $400 million in annual federal reimbursements.

“Planned Parenthood operates just like every other health care provider in this country that provides abortion services. We get reimbursed for preventive care,” she explained.

“I guess if you want to reduce unintended pregnancy and the need for abortion, the last thing you should do is try to deny women the access to family planning,” Richards said.

Tom Glessner, the president of the National Institute of Family and Life Advocates, which lobbies against abortion, is optimistic about the projected savings for the federal government.

“On the positive side, taxpayers benefit from this provision,” he told NPR.
“Taxpayers would spend $156 million less, over a decade, by defunding Planned Parenthood, even if women used more Medicaid dollars during their pregnancies.”

Glessner was referring to the increase in births the CBO projects if Medicaid patients are cut off from Planned Parenthood. The costs associated with about 45 percent of all births in the U.S. are paid for by the Medicaid program.

“In the one-year period in which federal funds for Planned Parenthood would be prohibited under the legislation, the number of births in the Medicaid program would increase by several thousand, increasing direct spending for Medicaid by $21 million in 2017,” the CBO report notes.

The Republican plan technically cuts off funding to Planned Parenthood for only one year. If the organization stops providing abortions, it will be eligible for Medicaid reimbursements again. But Richards said there is no chance that will happen.

“We provide full reproductive health care for people in this country,” she said. “And even though abortions may make up a small portion of what we do, women and families and young people come to Planned Parenthood because they count on us to be on their side, and to provide them with health care they need.”

Federal spending on abortions is already illegal, except in the case of pregnancies that are the result of rape or incest or that threaten the life of the mother, as NPR has reported.

Republican lawmakers and some clinicians have said that if Planned Parenthood closes clinics, other health providers would try to take on those patients. But community health clinics say they are already overburdened.

The Republican plan currently calls for tens of billions of dollars for states to spend as they see fit, including on preventive care for women.

“How will the states use that money? They have great flexibility,” Douglas Holtz-Eakin, former director of the Congressional Budget Office and current president of the conservative think tank American Action Forum, told Ari on Tuesday.

“They can give it to insurers as reinsurance for expensive patients; they can give it directly to individuals to cover out-of-pocket costs; they can create a variety of other programs like high-risk pools for expensive patients.”

But Richards argued that spending would need to address a supply problem in rural or poor communities.

“The public health community has been abundantly clear that they cannot absorb the 2.5 million patients that Planned Parenthood sees each year,” she said. “And particularly for women who have found a lump in their breast or need birth control immediately, and maybe a community health center can see them in a month or two months, that’s not good enough.”

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NPR’s Ari Shapiro talks to Douglas Holtz-Eakin, former director of the Congressional Budget Office, about the CBO report on the cost of the latest health care bill and the group’s overall reliability in predicting the cost of such legislation.

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