Medicare will pay for OxyContin immediately, no questions asked. But the new FDA-approved pain medication, which doesn’t risk addiction? That requires prior authorization, mandatory trials of cheaper drugs first, and maybe — if you’re lucky — coverage sometime next year.
Welcome to American healthcare, where federal bureaucrats have decided addiction is cheaper than prevention. Sixty-five million seniors are learning this lesson the hard way.
[W]hile generic opioids flow freely through Medicare’s approval system, this safer alternative is out of reach for many Americans because of the system’s bureaucratic obstacles…
Earlier this year, the FDA approved the first new classes of non-opioid pain medications in over 20 years. It blocks pain signals before they reach the brain, providing relief without the addiction risk medications such as OxyContin come with — nothing short of a monumental breakthrough after decades of watching the opioid crisis destroy families. Yet while generic opioids flow freely through Medicare’s approval system, this safer alternative is out of reach for many Americans because of the system’s bureaucratic obstacles, which all but guarantee most seniors will never access it. (RELATED: The OxyContin Story)
The so-called “step therapy” used in this system encapsulates the backwardness of our bureaucracy. Medicare Part D plans require patients to “fail first” on cheaper medications before covering more expensive alternatives — something which makes sense when the differences are minor. But when it comes to an issue such as opioids, while they are wracking our country, cost should not be placed ahead of lives.
According to American Journal of Managed Care data, 35 percent of patients report that step therapy negatively impacted their satisfaction in life, while 20 percent experienced overall health declines during these forced medication trials. When such trials involve opioids — which is common, given Medicare’s current policies — the result is sadly predictable: double-digit percentages of users develop persistent use.
Medicare plans that cover drugs do so by looking at just one number — cost. Journavx costs roughly $400 for a two-week course, while generic opioids cost about $0.50 per dose. This misses the bigger picture entirely. However, addiction treatment, all too common among opioid users, costs $18,000 annually. This crisis is estimated to have drained over a trillion dollars from the economy.
Still, Medicare remains stubbornly focused on its own balance sheet. Journavx matched opioids like-for-like at raw pain relief in trials, but since it didn’t beat them outright, bureaucrats have their excuse to let Part D plans keep pushing the cheaper, addictive option.
Price points aside, the human toll of these policies is appalling. America lost over 80,000 people last year from drug overdoses. Opioids were behind most cases. Prescriptions are often the gateway, with 40 million Americans receiving opioid prescriptions annually, despite addiction risk increasing after just three days of use. Throughout so many of our cities, homeless camps of chronically addicted people have popped up.
This has also taken its toll economically. The crisis has cost America an estimated $2.7 trillion in 2023 alone, according to the White House. That’s nearly 10 percent of the entire economy, up from $1 trillion just six years earlier. Medicare spent $33 billion treating members with opioid use disorders in 2022, yet it continues pursuing policies that push more seniors into that pipeline.
Not all federal bureaucracies have taken such a blind approach to the situation. The Department of Veterans Affairs demonstrates what happens when a healthcare system prioritizes patient safety over short-term savings. The VA implemented an approach that prioritizes non-pharmaceutical methods, systematically integrating various approaches as alternatives to opioids as standard care components to be tried first, not as a fallback once someone has already “failed” on pills.
The results speak for themselves. The VA pays 54 percent less than Medicare for drugs while achieving superior outcomes — more than 600,000 veterans successfully reduced their opioid dependence while maintaining effective pain management through alternatives. That’s not even factoring in the tens of thousands who never started the pills in the first place.
The rest of the world figured this out long ago. Americans consume four times more opioids per capita than Europeans, who prioritize comprehensive pain management over quick pharmaceutical fixes. Germany’s insurance covers non-drug treatments as standard care. French overdose rates are a fraction of ours. Meanwhile, Congress is twiddling its thumbs on the Alternatives to PAIN Act, which would completely eliminate the time-consuming and bureaucratic system of prior authorization and cost sharing for non-opioid alternatives.
The fix requires neither breakthrough research nor massive spending — just Medicare administrators willing to stop treating addiction as an acceptable cost of doing business. Every senior forced to try opioids before safer alternatives represents a deliberate choice by bureaucrats. The medications exist, the evidence is overwhelming, and the VA has already shown what works. Until Congress and Medicare act, the system will keep forcing over 60 million seniors through the addiction gauntlet, proving that in American healthcare, moral bankruptcy comes with a body count.
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Kyle Moran is a political commentator with Young Voices, specializing in international affairs and national security. His research on the Middle East has been published in the American Enterprise Institute’s Critical Threats Project, and his commentary has been featured widely in outlets ranging from RealClearPolitics to the Washington Examiner.