In Florida, Gov. Ron DeSantis signed a bill last week that, if federal authorities give it their go-ahead — still a very big if — would allow his state to import prescription drugs from Canada. That makes Florida the third state to pass such a law, joining Vermont and Colorado. More such legislative attempts are in the works.

“There have been 27 different bills proposed across the country this year,” says Trish Riley, the executive director of the National Academy for State Health Policy. “I think that it’s an approach that makes sense to states. It’s something they can do now to help their citizens.”

The Trump administration has made bringing down the price of prescription drugs a priority, and politicians at every level are looking for ways to make that happen.

Riley says her group didn’t help write the Florida plan, although it met with staff and provided resources and model legislation.

“States are very much frustrated by the incredibly high costs of drugs,” she says. “When you’re a state and you have to balance a budget and you pay for so much prescription drugs through your state employee plan, your municipal workers [and] through Medicaid, the cost of drugs really is front and center. So I think this is very much a bipartisan issue of urgency at the state level.”

Prescription drugs are often significantly cheaper outside the United States.

“Canada negotiates drug prices just like many other countries around the world,” explains Rachel Sachs, a law professor at Washington University in St. Louis who studies prescription drug pricing. “In the U.S., we’ve constructed a system where pharmaceutical companies are able to charge far higher prices because there’s no mechanism to push back — there’s no way to say, ‘We’re not going to pay for that drug unless we get it at a better price.’ “

So what exactly is Florida’s plan to import certain drugs from Canada, and how would it work?

The Florida law imagines negotiating with the federal Department of Health and Human Services to establish a pilot program to buy these medications from Canada in bulk. “The state would contract with a wholesaler in Canada, who would provide certain high-cost drugs that the state identifies to a wholesaler in Florida,” Riley explains.

So Floridian patients who have a prescription for one of those drugs would just go to their pharmacy and pick up their medicine as usual — all the importing from Canada would be happening in the background.

The law wouldn’t set up a way for Floridians to order medicines from Canadian online pharmacies themselves or enable them to drive north across the border to get a deal on the drugs. Rather, it’s a big-scale, institutional kind of plan.

Would Floridians even notice that their drugs were coming from Canada under this plan?

“It’s possible that the ability to purchase drugs for lower prices at the wholesale level translates into lower premiums overall for particular classes of patients or lower prices at the pharmacy for other patients,” says Sachs. “But without more details about the plan, it’s hard to know.”

And before Florida’s plan can become a reality, it still needs to clear some major hurdles.

First, the state needs to work out a lot of details — such as which Floridians and which drugs the plan would apply to.

The next hurdle is a big one: The plan needs to get approved by the federal secretary of health and human services, Alex Azar. Though the authority of the secretary to make such an approval has existed since 2003, no secretary has ever exercised that right. To win approval, Florida needs to show that the drugs it wants to import are safe and that the plan will save the state money.

On the safety front, Azar last year cited safety concerns when he, at least initially, dismissed the idea of importing drugs from Canada as a “gimmick,” in a meeting at HHS headquarters with the media and others.

“The last four FDA commissioners have said there is no effective way to ensure drugs coming from Canada really are coming from Canada, rather than being routed from, say, a counterfeit factory in China,” Azar said. “The United States has the safest regulatory system in the world. The last thing we need is [to have] open borders for unsafe drugs, in search of savings that cannot be safely achieved.”

A pharmaceutical industry group also has been running ads in Florida recently, talking about the dangers of counterfeit drugs. Riley, of the National Academy for State Health Policy, says those sorts of ads are misleading.

“I’ve seen those in every state we’re working in,” Riley says. “In fact, this program follows current FDA rules. It will use FDA-registered wholesalers. It will simply follow that same supply chain, those same protections, those same assurances of safety.”

Azar also said in that May 2018 speech that he doubted that importing Canadian drugs would save U.S. states or patients money.

“[This idea] has been assessed multiple times by the Congressional Budget Office, and CBO has said it would have no meaningful effect,” he said. “One of the main reasons is that Canada’s drug market is simply too small to bring down prices here. They are a lovely neighbor to the north, but they’re a small one. Canada simply doesn’t have enough drugs to sell them to us for less money, and drug companies won’t sell Canada or Europe more, just to have them imported here.”

Since those remarks last year, President Trump has urged Azar to work with Florida on its plan.

“President Trump and Secretary Azar are firmly committed to getting drug prices down,” HHS spokesperson Caitlin Oakley told NPR in a written statement. “They are both very open to the importation of prescription drugs as long as it can be done safely and can deliver real results for American patients.”

Of course, even if Azar has a change of heart, Florida would face another potential obstacle: getting Canadians and pharmaceutical companies to go along with the plan.

“They need to find willing suppliers for each of the drugs they’re aiming to import, and that may be more of a challenge than they anticipate right now,” says Sachs, the law professor.

Pharmaceutical companies won’t be inclined to cooperate, she says.

“They’ll lose money — if it works,” explains Sachs. “There are many things they could do all along the supply chain to ensure that drugs aren’t diverted to the U.S. in the way that Florida wants.”

Canada isn’t enthused about the idea either, Sachs says, because Florida’s laws could indirectly drive up the price of some drugs in Canada.

When you talk about importing “Canadian drugs,” points out Steve Morgan, a professor of health policy at the University of British Columbia, you’re not actually talking about drugs made in Canada or otherwise especially Canadian. “They’re not actually Canadian drugs,” he says. “They are just international medicines, manufactured typically at one or two plants worldwide to supply the entire market with a particular drug.”

If Florida’s Canadian drug importation plan were in place, Morgan says, “given the scale of manufacturing in the United States, if you were buying a drug made by and sold by an American pharmaceutical company, it’s likely you’re literally buying the same product shipped to Canada and then shipped back into the United States.”

So are Canadians worried that all 21.3 million Floridians are coming for their cheaper drugs? Not really, according to Morgan.

“Canadians feel that the policy is probably not going to result in millions and millions of Americans suddenly getting their drugs from Canada,” he says.

“As a consequence of the money to be made by way of being a middleman in the United States, I don’t think you’re going to see institutional purchasers suddenly shopping in Canada,” Morgan adds. “They will be able to get better prices by negotiating continuous discounts right there in the United States.”

And maybe that’s the point.

Just before Florida’s governor signed the bill last week at The Villages, a large retirement community outside Orlando, he said the law was already making a difference.

“It’s interesting,” DeSantis told a room full of Florida seniors who had been invited to witness the signing of the drug bill. “Since we’ve passed this bill, some of the American companies have already come to us saying, ‘Hey, we’re willing to deal and give you better prices’ — already, just for the fact that we have this.”

The room broke into applause.

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Texas is now among more than a dozen states that have cracked down on the practice of surprise medical billing.

Texas Gov. Greg Abbott, a Republican, signed legislation Friday shielding patients from getting a huge bill when their insurance company and medical provider can’t agree on payment.

Senate Bill 1264 is bipartisan legislation that removes patients from the middle of disputes between a health insurance company and a hospital or other medical provider.

“We wanted to try to take the patients — get them out of the middle of it — because really it’s not their fight,” says Republican state Sen. Kelly Hancock, the bill’s author.

Under the new law, insurance companies and medical providers can enter into arbitration to negotiate a payment — and state officials would oversee that process.

Surprise medical billing typically happens when someone with health insurance goes to a hospital during an emergency and that hospital is out of network. It also happens if a patient goes to an in-network hospital and the patient’s doctors or medical providers are not in network. Sometimes insurance companies and medical providers won’t agree on what’s a fair price for that care, and patients end up with a hefty medical bill.

Consumer advocates in the state have been urging lawmakers to do more to help Texans saddled with surprise medical bills.

Drew Calver is among the many Texans who have dealt with a surprise bill in the past few years. Calver, a high school history teacher in Austin, had a heart attack in 2017. He was rushed to the closest hospital by a friend that day, and doctors implanted stents to save his life.

Even though he had health insurance that paid the hospital more than $55,000 for his care, Calver ended up with a bill for $108,951.

Calver and his wife, Erin, fought with the hospital and the insurance company for months with little success.

The Calvers eventually turned to the media. Last summer, Drew Calver told his story to the Bill of the Month investigation from NPR and Kaiser Health News. Shortly afterward, his bill was slashed to just $332. Erin Calver says she has seen her family’s story strike a chord.

“For whatever reason, people could relate to us — and be scared that maybe it could happen to them,” she says.

Drew Calver says it’s something lots of people worry about.

“The doctor that put my stents in — he either just had a baby or is about to have a baby — and he was saying that, ‘Yeah, that could happen to me too!’ ” Drew Calver says.

In fact, getting a steep hospital bill is something more Americans say is their biggest financial fear.

“Polling shows us that the top household pocketbook concern for consumers is a surprise medical bill,” says Stacey Pogue of the Center for Public Policy Priorities, a think tank that analyzes health and economic issues in Texas. “And that’s actually pretty shocking that consumers will say they are more worried about their ability to afford a surprise medical bill than their health insurance premiums [and] their really high deductibles.”

Last year, a Kaiser Family Foundation poll found that 67% of people worry about unexpected medical bills — more than the percentage who worry about prescription drug costs or basic necessities such as rent, food and gas.

Pogue says that’s a big reason lawmakers in the state took the issue seriously and passed legislation that she says is now one of the strongest state protections she has seen.

“It is as strong or stronger than any of the protections in the country,” Pogue says.

In addition to Texas, nearby states Colorado and New Mexico also passed legislation this year to address the problem of surprise out-of-network bills. The Commonwealth Fund’s most recent report on the issue found that about half of states offer some legal protections from surprise bills, but only six states had laws that provide “comprehensive” consumer protections, similar to those just passed in Texas.

Texas’s new surprise-bill law officially goes into effect on Sept. 1, 2020.

Hancock, the state senator, says the fight over who pays disputed bills will be back where it belongs: with insurance companies and the hospitals, doctors and labs providing medical care.

When a hospital and insurer can’t agree on a price, the two parties will have to work it out — without ever billing the patient.

“There is still the ability to negotiate,” Hancock says. “You didn’t have government determining what the price was or determining what the settlement was.”

But not all Texans will be protected by the new law, which does not apply to people who have federally regulated plans. In Texas, federally regulated plans account for roughly 40% of the state’s health insurance market.

In fact, Drew Calver would have been exempt from the state’s protections because until recently he had a self-funded health plan regulated by the federal government. However, the family switched to his wife Erin’s health plan, which will be subject to these new protections.

Pogue says people around the U.S. who have federally regulated health plans will be protected only if Congress acts. She thinks the state action will spur federal lawmakers.

“And I think Texas passing a bill will really help on that front,” she says, nothing that several other states have created similar laws. “Every nudge like that is going to help Congress move.”

Texas lawmakers did, however, pass separate legislation that could help Texans with federally regulated plans. Senate Bill 1037 prevents a surprise medical bill from affecting someone’s credit, regardless of whatever health insurance plan the person has.

Congressional leaders have said they are working on coming up with a fix for people across the country with federally regulated plans. Also, President Trump recently held an event at the White House, with Drew and Erin Calver standing by his side, announcing his administration’s support for banning surprise medical billing throughout the country.

During a U.S. House Ways and Means health subcommittee meeting in May, members discussed ways to ban the practice of surprise medical billing.

The subcommittee’s chairman, Austin Democrat Lloyd Doggett, said that “federal action is essential” to addressing the issue for many Americans with federally regulated plans. He said he plans to continue to push for legislation that will “finally offer some relief to patients.” However, no legislation has been passed yet.

During his opening statements, Doggett said there is a bipartisan desire to shield patients from surprise bills, but “conflict remains over how to resolve insurer-provider disputes.”

This story is part of NPR’s reporting partnership with KUT and Kaiser Health News, an editorially independent news service of the Kaiser Family Foundation. You can follow Ashley Lopez on Twitter: @AshLopezRadio.

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Dr. Louise Aronson says the U.S. doesn’t have nearly enough geriatricians — physicians devoted to the health and care of older people: “There may be maybe six or seven thousand geriatricians,” she says. “Compare that to the membership of the pediatric society, which is about 70,000.”

Aronson is a geriatrician and a professor of medicine at the University of California, San Francisco. She notes that older adults make up a much larger percentage of hospital stays than their pediatric counterparts. The result, she says, is that many geriatricians wind up focusing on “the oldest and the frailest” — rather than concentrating on healthy aging.

Aronson sees geriatrics as a specialty that should adapt and change with each patient. “My youngest patient has been 60 and my oldest 111, so we’re really talking a half-century there,” she says. “I need to be a different sort of doctor for people at different ages and phases of old age.”

She writes about changing approaches to elder health care and end-of-life care in her new book, Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life.

Interview highlights

On how people’s health needs become more complicated as they age

While old age itself is not a disease, it does increase vulnerability to disease. So it’s the very rare person over age 60 … and certainly over age 80, that doesn’t tend to have several health conditions already. So when something new comes up, it’s not only the new symptoms of potentially a new disease, but it’s in the context of an older body of the other diseases, of the treatments for the other diseases.

If somebody comes in with symptoms and they’re an older person, we do sometimes find that single unifying diagnosis, but that’s actually the exception. If we’re being careful, we more likely find something new and maybe a few other things. We add to a list [and], we end up with a larger list, not a smaller one, if we’re really paying attention to everything going on in that person’s life and with their health.

On how the immune system changes with age

Our immune system has multiple different layers of protection for us. And there are biological changes in all of those layers, and sometimes it’s about the number of cells that are able to come to our defense, if we have an infection of some kind. Sometimes it’s about literally the immune reaction. So we know, for example, that responses to vaccines tend to decline with age, and sometimes the immunity that people mount is less. It also tends to last less long. And that’s just about the strength of the immune response, which changes in a variety of ways. But our immune system is part and parcel of every other organ system in our body, and so it increases our vulnerability as we get older across body systems.

On the importance of vaccines for older people

Older people … are among the populations (also very young children) to be hospitalized or to die as a result of the flu. The flu vaccine, particularly in a good year, but even when the match isn’t perfect in a given year, [protects] older people from getting that sick and from ending up in the hospital and from dying. … That said, we have not optimized vaccines for older adults the way we have for other age groups. So if you look, for example, at the Centers for Disease Control’s recommendations about vaccinations, you will see that there are, I believe, it’s 17 categories for children, different substages of childhood for which they have different recommendations, and five stages for adulthood. But the people over age 65 are lumped in a single category. … We’re all different throughout our life spans, and we need to target our interventions to all of us, not just to certain segments of the population, namely children and adults, leaving elders out.

On how medications can change in how they affect the patient over time

Researchers have traditionally said, “Well, we’re not going to include older people in our studies because their bodies are different and/or because they have other ailments that might interfere with their reaction to this medicine.” But then they give the medicine to those same older people … and so very frequently with a new medicine we will see all sorts of drug reactions that are not listed on the warnings. So message number one is just because it’s not listed doesn’t mean it’s not the culprit. Another key point is really any medicine can do this. And it can do it even if the person has been on it a long time. … We think of medicines as sort of fixed entities, but in fact what really matters is the interaction between the medication and the person. So even if the medication stays the same, the person may be changing.

On the importance of doing house calls in her work

What got me into medicine and what keeps me there is the people. And when you do a house call, you see the person in their environment, so they get to be a person first and a patient second, which I love. I also can see their living conditions, and more and more we’re realizing and paying attention to how much these social factors really influence people’s health and risk for good or bad outcomes.

Roberta Shorrock and Seth Kelley produced and edited the audio of this interview. Bridget Bentz, Molly Seavy-Nesper and Deborah Franklin adapted it for Shots.

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