This episode features audio from Public Pharma, Public Power: Taking Back Control of the Medicine Supply. It was recorded on September 28, 2026.
Access to affordable medicine is a human right. Yet across the United States, drug prices remain out of reach for millions, with the heaviest burdens falling on Black, Latino, Indigenous, and other communities long excluded from equitable care. At the same time, a profit-driven pharmaceutical system drains public resources and puts enormous pressure on the health systems communities depend on.
Public pharma offers a different path. This panel will explore three urgent questions:
Why is the current system failing us? Market failures, perverse incentives, and extractive private actors throughout the pharmaceutical supply chain – from research and development to manufacturing to distribution – keep life-saving medicines unaffordable for the people who need them most.
What can public pharma actually do? Public options at every stage of the pharmaceutical value chain can create real competition, check private power, and deliver on government’s fundamental responsibility to ensure people can access the medicines they need.
Where is this happening right now? Public pharma initiatives are gaining momentum across the country. Our panelists will share what is working, what we are learning, and how these efforts are building toward lasting systemic change.
Announcer 0:01
Welcome to Engelberg Center Live, a collection of audio from events held by the Engelberg Center on Innovation, Law, and Policy at NYU Law. This episode features audio from Public Pharma, Public Power, taking back control of the medicine supply. It was recorded on September 28, 2026. 2026.
Dave Chokshi 0:24
All right. Well, good evening, everyone. I can't tell you how wonderful it feels to be in in this room this evening, and it's really my privilege to get to welcome all of you tonight on behalf of the Health and Political Economy Project, based here at the New School, as well as our colleagues in the Partnership for Public Pharma, we get to kick off what I think will be an important and stimulating evening together. I'm Dave Choxi. I get to serve as co-chair of the Health and Political Economy Project, or HPEP. I'm also a doctor at Bellevue Hospital, and I previously served as New York City's health commissioner. Our mission at HPEP is to build a just and inclusive economy that enables all people to experience health and dignity. We work to both shift paradigms and build power to realize this vision-an approach I hope you'll see reflected in our program tonight. HPEP aims to catalyze a field of partners, really like all of us gathered here, and and it spans organizers, practitioners, patients, and public servants. What binds us is that we have deep conviction that now is the moment to ensure big ideas gain traction and actually promote change. Public pharma is one of those big ideas. At its core, public pharma is about contesting, and I might say reclaiming the immense power private corporations currently hold over access to medicines. I must emphasize that these are our medicines. They are made by scientists trained with public dollars and built on research seeded by public coffers, and they are medicines we can't forget that are also made for us, our loved ones, our neighbors, our patients, ourselves. And public pharma is an idea whose time has come. The reason is a convergence of three things. First, affordability challenges across both health and our broader economy are being felt widely. I see it during every single one of my clinic sessions. Second, federal cuts, especially through HR one, will have compounding effects on both pocketbooks and patients, falling along the same lines of race and class that already shape who gets care. Like so many of you, I am very worried. And third, public pharma initiatives from CalRX to the New York Affordable Drug Manufacturing Act are mature enough to be injected into the broader policy dialog. We'll have to raise our expectations of public systems to deliver care and invest in them as critical elements of that dialog. Okay, onto the fun stuff. Big ideas require many minds. A year ago this week, after an event much like this one, hosted by T1 International and the Science, Health, and Information Clinic at NYU Law, a group of us came together to discuss the public pharma initiatives we were seeing gain momentum. By the end, we had named ourselves the Partnership for Public Pharma, or P3, and have continued those conversations over the course of the past year. Here, I have to give a shout out to the director of HPEP, Ms. Mara Hennigan, here in the back, who more than anyone deserves the credit for making p3 into something that we're all very proud to be a part of now. Our panelists tonight are all active members of p3, and I hope it's okay if I make a challenge for all of us, which is to turn the conversations of the past year into collective action in the year ahead. What is it that we have to do to turn conversations into collective action? Okay, so without further ado, let's kick off our program. We are really fortunate to have New York State Senator Gustavo Rivera with us. Tonight, welcome. And it's really my pleasure to introduce you, Senator. Senator Rivera has represented the 33rd Senate District in the Bronx since 2011, and his commitment to a just, inclusive, and sustainable health system for all New Yorkers is evident across his legislative career. He has served as chair of the Senate Health Committee for nearly eight years and is the first person of color to hold this role. Senator Rivera has passed measures to eliminate medical debt and protect patients against financialization, measures to expand health coverage for new new mothers, and measures to establish safe staffing in hospitals and nursing homes.
Dave Chokshi 5:45
He's also a leader in efforts to address the opioid crisis and a champion for universal health care. Most germane to our conversation this evening, Senator Rivera is the prime sponsor for the New York Affordable Drug Manufacturing Act. and a great partner to p3 members on this work. And look, on a personal note, I have to add, I got to work with Gustavo during the COVID 19 pandemic, and I don't know if you remember, but I even
Gustavo Rivera 6:19
had to forget, bro.
Dave Chokshi 6:20
I even vaccinated you a couple of times, so I know firsthand that he has the muscles to help make public pharma a reality in New York. So please join me in welcoming the Honorable Gustavo Rivera.
Gustavo Rivera 6:41
Good afternoon, good evening to everybody. First of all, two things. First of all, you said you know big ideas. I thought you were saying big ideas require big dudes. There
Gustavo Rivera 6:52
you go.
Gustavo Rivera 6:52
And as far as yes, Dr. Choxi is correct. We we did interact plenty during that that forever year, however long it was, and I and I did tell him something when I saw him just now, which is true. So I've been in in the in office for 16 years, and in that time, there's been many folks who I've known who have left public service, whether it's because elected officials who've been defeated, who have retired, folks who have been in agencies, etc. And he proved once again what I know to be true. I saw him just now, and I said, "How long ago? I don't know how long ago since I've seen you, but you now, after you left public service, look younger, like you, like you rested well last night, like you slept, like you're like you're happy with your life. And it annoys me, respectfully. Respectfully, it annoys me. I know, but but it is a great pleasure to be with you. So good evening to our all. So again, my name is Gustavo Rivera, State Senator for 33rd District in the Bronx, Chair of the Health Committee in the Senate for the last seven or eight years, and I I wanted to cover a couple of quick things, and then obviously pass it to to the panel. I believe, and I figure I am going to guess that everyone in this room would agree with me when I say healthcare is a human right. Right? We start with that, and if we start with that, then we obviously have to create policies that go in that direction. And lo and behold, we're not being too good at that right now. And so I'll talk very briefly about. I was going to do two, but I'll do three. But those be quick. I'll linger on the first one because certainly it's one of the ones that you're going to be digging more more deeply into today. The Affordable Drug Manufacturing Act. That is a bill. If you do not know it, we would be. I although I hate following any state, I hate another state beating us. In this case, California already did it, but I am also a big believer that legislation is the only place where plagiarism should be encouraged. So we are so we borrowed ideas from this bill in California, and ultimately, what we would do as a state is to partner up with private corp with a private company to create state produced generic drugs, starting with insulin. So the idea is obviously we would produce it for use in our own in publicly subsidized programs like Medicaid. So we would have Medicaid patients or insulin patients have a drug that is produced, manufactured by a company that is not a for-profit company, or there basically it would be for us, right? We would create it would be a partnership for us, and they might make some money on it, but it would not cost us anywhere near what it costs us to go to a private pharmaceutical company. Which, by the way, as a parenthesis, when I think of the top three evils in the healthcare system, for me, pharmaceutical companies are number two. Insurance companies are number one, by the way, which is where the other bill that I just wanted to mention quickly-the New York Health Act-comes into effect, and the New York Health Act, yes, that one does deserve some applause too, and that is a bill that I will, we will pass in this freaking state, which will create a single payer. System in the state of New York, guaranteeing every single New Yorker healthcare, not an insurance product. Not about expanding care. When you say expanding care, what most people mean is giving more people insurance products. We know how wonderful that that is because insurance companies are my favorite. If you didn't know, now you know. But New York Health Act is also a bill that I have that I that I feel very very strongly about. And last but not least, I also wanted to mention a bill which we refer to as the Cure Act, and that is the or the Cure Bill. This was brought to me by a state legislator from I want to say Ohio a few years ago.
Gustavo Rivera 10:37
And although it is a it is a longer term project, it is one that I've actually absolutely believe in. It would create a multi-state compact, which would basically say, if you're the state of Ohio, I'm the state of New York, and then we get a couple of other states. We would then put a we would commit to putting funds into a into a pot, and we would say to people, if you can come up with a cura, not treatment, if you could come up with a cure for something, let's say a cure for diabetes or a cure for you know, and name any disease that you might want, if you could create a cure for it, then we would actually pool together money to actually purchase that cure from you, then be able to produce it as a state, as a series of state compact, as a series of as as a series as As as a as a series of states that has entered have entered that compact. The goal here would and the calculation of it would refer to, for example, the amount of money that we would save as a state to be able to say we don't have to treat. Let's say let's take again diabetes. Let's say if we were able to get a cure for diabetes, then we would not have to pay for insulin. People would not have to pay for insulin on a on a monthly basis. We know that that's one of the reasons why cures are not necessarily something that is sought by the pharmaceutical companies because they wouldn't be able to make money every month. But we would. But that is a bill that I have that would do something like that would create an incentive so that if you are, even if you're a private for-profit company, we would then be able to purchase that from you and produce it, and in very much in the same, in a very similar way as the first bill that I mentioned, the Affordable Drug Manufacturing Act would do. So, ultimately, these are legislative proposals. They all require certainly the work that I'm doing internally, but I am very glad to be having the conversation with folks outside because ultimately none of these can get any traction unless there is pressure. I will finish by saying this across the board, whether we're talking about this, these bills, or anything else, teach you a little lesson about politics or government. This is the way I think about policymaking. You either you want to do two things: either you show them you you you turn on the light, or you turn up the heat. Those are two things. You can either educate someone about why a certain set of policies is a positive thing to do, how something that you do will actually change people, or you make it a political liability for people not to be on your side. You turn up the heat. You make it known that this is something that you need done, something that's going to impact people. If you don't act, then the things that are happening, the bad things, are your fault as an as a you know as a policymaker. So you either turn on the light, turn up the heat, or do a little bit of both. But ultimately, what I just all that I need, all that I wanted to do tonight was just to turn on the light a little bit. So, thank you so much for having me here this evening. That's
Dave Chokshi 13:34
it. Yes, I'll I'll just say on on behalf of all of us, Senator means a lot that you joined us this evening, and we are alongside you as you turn up the lights and turn up the heat. Thank you. All right, we're turning it over to Mara.
Mara Heneghan 14:03
I think our panelists can come by me as well. All right. Let's see. All right, hi everybody. Thank you so much, Senator Rivera and Dave. We deeply appreciate both of you for helping us champion this work, and for opening our conversation. As mentioned, I'm Mara Hennigan, director of the Health and Political Economy Project at the Institute on Race, Power, and Political Economy at the New School. Thank you to everyone for joining us tonight. I know you've had to survive a weekend of rain and a day of rain to get here, so we're very grateful. And as our panel. Let's get settled in. I just like to give us some quick context for the conversation we'll have. As Dave mentioned, public pharma can encompass many things. The pharmaceutical value chain, as we'll start to learn tonight, is very complex, spanning from research and development to manufacturing to purchasing and procurement to distribution. We are eager to seed approaches across all of these that pursue bold strategies and at every level of government, but we wouldn't have time to discuss each version of that tonight. And so we'll ask our panelists as they walk us through different stages of the value chain to talk about a concrete example at the state or local level that really helps us imagine what these initiatives can look like and talk through current and proposed plans. We'll focus on manufacturing, purchasing and procurement, and distribution. And similarly, the approaches, tools, authority, and resources available across levels of government might be something we go back and forth on because we'll be going back and forth between state and local government. Finally, I want to say that the ideas we're discussing tonight represent policy fights we really do believe we can wage and win now. And so you'll hear some very exciting momentum, both located here in New York, as I know we have many champions of in this room, as well as across the country. The through line here is that absent public capacity in the pharma sector, we can expect private pharma companies to keep pursuing profits by overpricing what is profitable, like GLP-1 medicines, for instance, and underdelivering what isn't, like tuberculosis drugs, we fundamentally believe this is an unacceptable structure for producing essential goods and an unsustainable system for a system we all rely on. And with that, I think I will turn it to Shaina, Allison, and Matt. Shaina, Shaina. executive director of T1 International. Allison is the community development director of T1 International, and Max is the chapter leader of T1 International New York's Insulin for All chapter. As you'll hear, T1I is a patient-led nonprofit fighting for global healthcare equity in the diabetes access to medicine space. They are also a co-convenor of the Partnership for Public Pharma and a leader in the push for public pharma legislation across the U.S. Shaina, Allison, Max have each been really essential to these efforts and wonderful partners in the creation of p3. And I'm so excited to hear from them tonight.
Shaina Kasper 17:17
Thanks, Gilles. Yeah, perfect. Thanks. So hi, yeah. I'm Shaina Casper. I use she/her pronouns. Hi, it's so fun to see so many Insulin for All folks in the room. This is so exciting. This is my first time using the clicker. I'm so sorry. Is it gonna work? No. That one has the scary red button, but that one also didn't work. Great. It's okay. Okay, so I'm just going to share a little bit about kind of T1 International's work championing public pharma in the U.S. and around the globe, just kind of as a as an overview. Oh, thank you. Great. But so yeah, as Mara said, T1 International we work at in the access to medicine space in the in the diabetes space for global healthcare equity, and then if you go forward, our we have our our mission and our and our our values there as well. But I'll just go through that all really quickly. More to say of talking about just kind of why why insulin, and I I just want to start off by saying that the insulin price crisis is not over. Maybe some of you have been hearing about $35 insulin. Everyone should have access to $35 insulin. All these policies have been have been happening through the years, and yet our data is really showing that over. If you go to next slide, sorry, I'm gonna have you keep doing this. And one more, here we go. Over 30% of patients at our most recent out-of-pocket expenses and rationing survey, have rationed insulin due to cost, and that is double the number when we started collecting this data back in 2016. And it's it probably it may even be even higher than this. When I joined the team at T1 International back in 2021, I didn't think that I had been rationing my insulin, and it wasn't until I had like worked with the team and I really understood that what I had done of going to a pharmacy, needing one more vial of insulin to get through my trip before I could make it home, handing over my credit card and having that credit card denied, and be like, "It's I'm fine. I'm a professional. Like I, I, I, I should be able to access my insulin. This is a personal failing. It wasn't until I started on the team that I realized that what I had done there was actually was that rationing of insulin, and that that was what people had been talking about when it was. This was a systemic problem. This was not a personal failing, but that because of the price of insulin being too high, because our structures and systems are not set up to support patients, that's what led to to my rationing of of insulin back in 2019. So, I think insulin's a really good case study because it's really putting case case study and and test case for public pharma because it is so essential. Going just a couple of hours. Without insulin, can lead to can lead to severe health consequences, diabetic ketoacidosis, and even death. And you know we have we we're all in this fight because we're we're all terrified of that eventual that what would could be happening, and and that the reason that the insulin price is so high is because of this market. the The market has this corporate monopoly where there's only these three manufacturers: Eli Lilly, Novo Nordisk, and Sanofi, who are producing over 90% of the world's insulin by volume. And also, just wanting to say before diving into a little bit more, is that this case study of insulin is just so real. It's so tangible. It's not this abstract idea. It really, it's happening, as as Senator Rivera said in California, and we can really see see that happening. So, if we go to the next slide, great. So at TN International, you know, we really combine the data with this moral righteousness of of of the insulin price crisis. So, as Senator Rivera said, we we turn up the heat. We're on the side of turning up the heat. There's a lot of amazing researchers and and folks collecting the data.
Shaina Kasper 21:11
We do some of that data collection with our out of pocket expenses and rationing survey, but that we really work to ensure that those who are most impacted, you know, patients, people living with at the front lines of the crisis, living with diabetes, or having loved ones live with diabetes, are the ones being able to share their powerful personal political stories with policymakers, with stakeholders to really fight for that long-term change. And what we've seen too with the just talking about the data, like shining the light, is that the price of insulin is completely disconnected from the cost of production, right? So the as it says, vial only costs a couple of dollars to produce, and yet is being sold for over $300 a vial in many cases, and this this really combination this combination of the monopoly control, the human suffering that is caused from the high prices and this price distortion in the market has has meant that it is really a compelling case for for public intervention. And so I think only one more slide here too. But yeah, just to kind of give like a quick overview of some of the things that we've been working on, we've had some. Yeah, as I said, our work is to really create the political conditions to to make public pharma and other these long term solutions possible, and some of the tangible wins. And we we started in in 2018 pushing in California and Washington. We'll be hearing a lot more about California's case study here as well of working on public public production that started well before this with California's baby big program for infant botulism, Michigan's vaccine production. We've seen these wins before, but in the insulin case study, in this kind of public procurement partnership, is really a powerful example, and then we've also been seeing what Stephanie's going to be talking a lot more about too in Washington, Oregon, Nevada, Ohio, Connecticut, Arizona, and most recently in Vermont, where I'm from, of joining ArrayRX in some capacity to to fight costs, where states can really take this meaningful first step to make drugs more affordable and accessible to their constituents, while really still exploring those long-term changes like public manufacturing and other things like that. So that's kind of I'm hoping to give like the lay of the land why why we're talking about insulin when we're talking about public pharma, and now I'm going to hand it over to Allison to dive more into the California case study.
Allison Hardt 23:46
Thank you, Shaina, and thank you, everyone. So glad to be here. So yes, as Shana shared, we've been involved in the movement for public pharma for many years, and really just seeing this as the solution for for the crisis that we're facing, we know that there's not going to be a perfect solution, and there's no one size fits all option. But we have really strong frameworks available now through these public pharma policies, and so I'm going to talk a little bit about Calorex as as a case study, as something that has is already happening, and so as has been discussed through legislation, California established their own drug brand, Calorex, and used insulin as kind of the first drug that they were going to target. And that was back in 2020 when that legislation was was passed. And so fast forward to now, as of January one st of this year, we do have a box of five insulin glargine pens is available at a stable, transparent price of $55. It's a $45 price, and then there's a $10 pharmacy dispensing fee that's kind of built into that. But that is available without having any rebates or any coupons. Or any other barriers, hoops to jump through regarding insurance. You just walk into the pharmacy and get that price. And I just have to emphasize, like, how significant that really is for people who are living with diabetes, because it's very rare that you can just walk into a pharmacy and actually know what your prescriptions will cost. It's it's a fun surprise every time. So, and and we also see. I feel like a lot of the barriers that we see for people are at the pharmacy counter at the point of sale. So despite what maybe happens in the policy space or out in the world, when it actually comes to the the real experience of trying to get the medicine, that's where people run into a lot of blocks. So the fact that this is available is is really huge, and I also want to just name that from day one, our advocates were really involved in this process. Not only advocating for the legislation, but then after it was passed, we advocated and successfully got the patient advisory council established for the Calorec's insulin program. So that has allowed patient voices and people with direct lived experience to really be informing the implementation of this as well, and to keep the lessons learned, keep sharing those out, and also to keep talking about how it can be improved because there are lots of improvements. And so we know that this isn't the whole solution. There's only this is one type of insulin. There are many types of insulin, but it is this really meaningful move towards having a stable, transparent price that you can access at the pharmacy counter, and we do have more insulins that are going to be coming. And then, really, really importantly for tonight's conversation is obviously what we talk about most is insulin at C1 International, but these policies are absolutely not just about insulin, and so that's what you can see here. So setting up the the state drug label of Calarax really allowed California to target needs nimbly as they come up and be able to work across their health department and many other stakeholders to identify what they could do and what those solutions would be. So for some drugs, this is contracting with a manufacturer to guarantee supply in exchange for a lower price for the state, like in the case of naloxone. For others, like insulin or most recently EpiPens, it's going to be drug development where they're investing in the actual drug development with a new player in the market, so that they have more competition. And that path is going to be the most viable for correcting the market failures that are happening, securing supply and also avoiding shortages. So to date, Calorex has, as it sits here, addressed insulin by securing that $55 box for five insulin pens. Supplied free naloxone to qualifying entities in the state, and also at $19 over the counter anywhere in the state. They have been able to provide albuterol inhalers for free for every California public school or charter school that started this summer on a three-year. The program will be active for three years, and then next steps will be decided.
Allison Hardt 27:51
And they are next going to be focusing on drugs for tuberculosis, which likely will mean contracting between states, pooling purchasing power to secure drugs at a lower cost and ensure the supply, since the issue with TB drugs isn't necessarily high cost, but is about inconsistent supply due to the fact that there's not a profit incentive for companies to produce them on a regular basis and as needed. They are also now focused on EpiPens, which will likely mean pursuing that drug development process, similar to what they are have done with insulin. So, next slide, and then this is just to really drive home the point that these policies are happening in many places, and that it is not something that that it's that has traction in many states. So, there are nine states that have legislation passed or introduced that have allowed them to explore what drug development or manufacturing on the part of the state would look like, either through contracting with an independent manufacturer, a nonprofit, or otherwise, or through their own state-owned manufacturing, laying the ground for groundwork for that potential. So these are all the states, and as this hopefully shows, they're building this this power, and that it's not a fringe idea. These are red and blue states, and it's a pretty large variety in terms of state size as well. And so, of course, every state is going to be different in how they're going to approach this. But as also I hope is going to be evident already, and will continue to be through this evening. We have a really incredible network of professionals across so many different specialties that are very collaborative and and have so much expertise and are ready to share. So anyone who's in the state policy space, we hope that we'll be able to connect. Also, Calarex specifically has a mandate in their paperwork that that they are supposed to be sharing their knowledge and their experiences with other states, so they are super open to talking about what what they are experiencing, what they're learning, how they debate their decisions. Again, it's not one size fits all, but there is collaboration and a willingness to have conversation. And so, just last slide, please. Or I'm doing. Now I'm sorry, Shane has got me. So this was just somewhat related, but I wanted to share this quote because serendipitously I was reading "Everything Is Tuberculosis, which is the new book by seeing smiles. People are like, "Yes, yes, yes. Yeah, really great, and I'm I'm learning so much about tuberculosis now because of our public-private policies. So, but this quote from Dr. Carol Mitnick, who's been working with Partners in Health for many, many years, and is at Harvard. And I'm just going to read it. It says, "This is a human manufacturing problem. Human manufacturing problem that needs a human solution. If medications were a public good, the burden of disease would drive the priorities of the industry. And I think that's really what this is all about. We'd want essential medicines to be thought of as public goods that people who rely on them can get them as they deserve. So, as we heard from Senator Rivera, there's so much momentum building right here in New York right now, and Max has been doing incredible work with our Insulin for All chapter in New York. And so, I want to pass this to him so he can share more.
Max Goldberg 31:03
Sweet, yeah. Thank you, Allison. Thank you, Shayna, and then thank you, Commissioner Choxi, and thank you to Senator Rivera for for opening us up. My name is Max Goldberg. I'm a type one diabetic, which means I need insulin every single day to stay alive, and I am the co-lead of Two Internationals New York Insulin for All chapter. Our chapter has been working over the last year to lead the campaign around the New York Affordable Drug Manufacturing Act that Senator Rivera mentioned, which would give New York this very powerful tool to address the extractive killer pharmaceutical system that insulin or insulin-dependent diabetics and so many other people know so well. So what I want to do is just kind of quickly talk about the bill and what it does. Introduce where we are heading into this year's legislative session, and then talk about the parts of the legislation and our campaign that might be relevant to folks in other states, like Allison mentioned, who are kind of pursuing similar ideas. And I think the best way I can think of to get into a lot of that information is just by thinking about where our chapter, which is entirely volunteer, made up entirely volunteers, kind of started and why we took up this campaign. So, this was a couple years ago now. Our chapter was restarting and had been dormant for a bit, but as we got back going, we entered into an interesting moment in like the insulin access landscape, right? We had just come out of this moment where there was a really bright federal spotlight on insulin pricing, but that was starting to dim. And just at the same time, the federal, both on a federal level and in New York State, they had very loudly passed these copay caps that God mentioned that made a lot of people seem to believe that the problem was solved. I think we, as diabetics, that we really appreciated a lot of that legislation and knew it was well intended, knew that it didn't solve the problem. We knew that people were still falling through the gaps, and that ultimately it left like the fundamental reality that we all face totally unchanged. That we as diabetics were still totally reliant on something that was produced by just three profit-driven pharmaceutical companies. So it's in that context that we started talking about what we, as a chapter, wanted to do, where we wanted to direct our efforts, and we talked a lot about some great legislation. We talked about emergency insulin laws. We talked about the New York Health Act that Senator Rivera mentioned. I think the thing that we kept coming back to, and the thing that we found energizing enough to really build a campaign around was this idea of creating a public option for drugs here in New York State that we could then rely on and trust. It's what motivated our chapter. It's what got people coming to meetings. It's what really, really allowed us to kind of build the infrastructure that we used to to get into some of our campaigns from last year. And I think what stood out to us, it was something that got to the root of the problem. It challenged big pharma's monopolies. It was something that would help not just diabetics, but folks who are relying on the other drugs that Allison mentioned, and really any drug that's monopolized by pharma. And then, importantly, it felt very winnable, and it felt like something that, in this near term, you had the real benefit, like short-term benefit of the state having this tool for public procurement of drugs to deliver kind of an immediate relief, and then in the long term you had this really transformative, exciting vision that a lot of people could get behind, which was true public development, manufacturing, and distribution of these essential medicines. So it takes us into last year, which was our first year campaigning for it on the state level, and I think as patient advocates with allies like the NYU Science Health Information Clinic and P3, we were equipped to talk to a lot of legislators, which was really helpful, and do a few key things.
Max Goldberg 34:34
We were able to, you know, of course, tell our stories, but I think specifically use the the spotlight that had been put on us as diabetics to tell the state that what they had done previously just wasn't enough, and that we demanded more from them. We were able to talk to legislators and answer their questions about feasibility. Public farming can sound like a big concept, but with Calorex and experts like Allison, I think we're able to show that there was real precedent for this, and then. We were able to socialize the bill, which was important, and I think something that we saw that is important to anyone who might be considering this legislation in another state or is supportive of public farm in general is that there was a lot there for a lot of different people. So we spoke to progressive legislators who saw this as like a really big step forward in the state's ability to to care for its citizens, we saw we spoke to budget hawks who saw this as something. Was that me or you? We spoke to budget hawks who saw this as like an unglamorous way to save the state money in places like switching over people who were on its New York State Employee Health Plan. We spoke to upstate legislators who were really really thrilled by the idea of in the long term bringing high-scale manufacturing back to post-industrial parts of the state like Rochester, we spoke to legislators who represent a high population of uninsured folks who just saw this as like a critical intervention to get medicine in the hands of people who needed it. So we had a lot of great conversations. Obviously, we're here now ultimately because we didn't meet our goal, and and we weren't able to pass the legislation this year. But I think we're in a great spot coming into this year to get it done, and and that's for a few reasons. One, Senator Rivera's leadership, which we're really grateful for. We also, after kind of not having the the allies we needed in the assembly, feel like we over the summer and early into this year, have new motivated champions in the assembly to get it passed through the assembly. We have the CalRX initiative to kind of keep looking at as they get insulin pens in people's hands, get inhalers in schools, and then as was alluded to by Senator Rivera as well, we have this like devastating federal landscape where we have folks getting kicked off the essential plan, and we have people all across New York who are needing some help with how they get their health care. And I think I want to kind of quickly use Center of Air's framework of you got to turn up the light and turn up the heat to talk about what we will do heading into next session. Turning up the light for us looks like continuing all that legislative work that I mentioned, but turning up the heat, I think, critically means going beyond the legislature and bringing more people into the the movement that we're building. I think we know what this piece of legislation can mean for communities all across New York. We know it can be life saving. It is our job now to go build with those communities and bring them into this fight. I think we have spoken to some folks at the New York City Department of Health and Mental Hygiene who have illuminated a few really, really devastating situations with tuberculosis drugs and syphilis drugs that New York Affordable Drug Manufacturing Act is like ready-made to remedy and address. That's a place we'll be building all the other use cases that that Allison laid out, and honestly, any drug you can think of that is monopolized by pharma Affordable Drug Manufacturing Act is a solution can be a solution to address it. So we are looking forward to doing all that work. I think when we think about how this legislation can be broadly applicable. Senator Rivera said that line about plagiarism-that it's good in state policy debates or contexts. That certainly applies here. This legislation is a tool that is meant to just give states capacity that they can apply to the context that they find themselves in.
Max Goldberg 38:17
And then I think beyond just the legislative context, we've seen as a chapter that one of the most transferable elements of these campaigns is that big pharma or sorry public pharma is an idea that is ambitious enough and and bold enough and exciting enough that it is able to mobilize and and motivate the people that you need to bring in to actually win these campaigns. So I think that was the part that really stuck out to us as a chapter, and I think when we think of other folks picking up this mantle and running with it, that idea of fighting for something that is like bold enough to actually make a difference in people's lives and show that the public sector has the capacity to intervene against these monopolistic corporations is incredibly valuable. And you know we have learnings. Dana Brown, Chris Morton, all these folks have learnings that we are eager to share. So with that, I will wrap it up.
Mara Heneghan 39:13
Is this mic okay? Can we? I just want to show the t1 I New York slide.
Max Goldberg 39:19
Yeah. So that that is our QR code for our New York chapter. That will be our the QR code. We also have flyers out from for the New York chapter that we will make sure to get to everybody, and that'll do. Let
Mara Heneghan 39:43
me pass a working mic this way for a moment. Sorry. We'll make sure to get you all the information on T1 International and the New York chapter for those whose emails we have, which I think is probably most people in this room because we were pretty devious about that. I think this lends into many. Manufacturing and production is a really good segue into what we'll talk about next, which is purchasing and procurement. The quick context I'll set for us there is that we often talk about purchasing and procurement as one of the place, and I know we have some public servants in the room. We talk about it as one of the easiest places that we think governments can start because it is a place where governments across levels are already spending billions of dollars to treat millions of people or cover millions of people. You can think about public health insurance programs like Medicare, Medicaid, Tricare, CHIP. You can think about places where people are receiving care, like the VA or a public hospital. You can think about people who are incarcerated in state and federal prisons and detention centers who also need medicine, and you can also think about employee health plans for state governments, local governments, who who can often be the one of the largest employers in the state, and so or in the jurisdiction. For New York specifically, we know that about 1.2 million people are covered by the New York State Health Insurance Program for employees, and another 1.2 million people are covered by the cities, and so each of those is about 6% of the state population of New York, and you're at 12 percent right there. If we just get creative and really kind of ask government to use the leverage it already has to think about both what it's providing to its employees, but also how it's connecting with some of the initiatives we were talking about today. You can scan this QR code to see a few pieces of writing that we've put out from HPAP this summer. One is an op-ed from Dave, and the that is very focused on New York City and state, and talking a little bit about purchasing and procurement in those contexts. And the other is a memo for policy for state policymakers on GLP ones and where we think there are public pharma strategies available to contend with the fact that those are really stressing state budgets right now. With that, I will turn it to Stephanie, who is going to talk us through a little bit more in depth the procurement and purchasing side of this puzzle.
Stephanie Krieg 42:00
Hey everyone, just want to thank everybody who's gone before me. Per usual, the TNI group always comes with thoughtful and innovative strategies and some really wonderful things. So just always appreciate when they're on the team. But my name is Stephanie Craig. I'm the senior advisor for health policy initiatives in Connecticut at one. one of our constitutional offices, and the way that I think about purchasing and procurement all the time is obviously as a public servant. So, in addition to doing health policy work, I manage the pharmacy benefits for the state of Connecticut employees. And so, what's really interesting about that work is that not only on one side do I really have to think about the policy and sometimes the abstract of it, but then I'm also kind of the person in the room who has to make sure that the work is going through. So we kind of I think about it from two different lenses. Not only you know is this a great policy idea, but also really thinking about how we can put it together in practice, and what each of the stakeholders in this room could probably do to support that-not only getting it into your states, but also implementing and evaluating if it's working. So the one thing that I always like to mention, and I'm sure you know the folks in this room are probably people who might know this, but you know when we say the government is a purchaser or a procurement in a pharmaceutical market, there's we really just think about sometimes the medicine itself, but we really have to think about how our public dollars procure pharmacy things in a variety of different ways, right? So government not only purchases the things that you think about, which are the drugs and the vaccines, right, and those medical products, but they also, you know, work with manufacturers. They have wholesaler contracts. They they work with pharmacies and dispensing services. Additionally, we procure pharmacy benefits, pharmacy networks, things like that, and then we also procure programs that increase access and affordability, or design programs that that increase access and affordability, and those purchasing decisions are happening all across government, whether it's state government where I work or your local municipalities as well too, and there isn't really one place that government participates in this market. We always love to lump purchasing and procurement into one space, but there's so many different avenues that it goes into, and there's multiple places where government can decide not only what it buys but also how it participates in the market. So today, my role is to really kind of highlight two existing things that are happening in the country right now, and really be able to highlight like how you guys might be able to support. So one of the first programs that I just wanted to highlight was this is something that's actually happening in the market right now. This is a MM Cap. It's a government operated cooperative purchasing. Organization and it's a really good example of shared public procurement infrastructure. So their scope is kind of broad. They it includes procurement of pharmaceuticals and vaccines, wholesaler and pharmacy services, as well as other healthcare products and services. They they have competitively procured contracts that public sector members can actually tap into and access, and it provides procurement and contracting infrastructure that public entities can use. It's already existing in the marketplace, and it's for a range of healthcare needs. It really gives public purchasers like me, who have limited time and bandwidth, the benefit of collective scale. Right? You know, it also has something that's equally important, which is the expertise and established contracting that already exists there. Especially when you're talking about governments, it's such a hard on-ramp. But when the existing structures are in place, it just makes it so much easier for buy-in for states because it's one less thing that we really have to think about. You know, every individual public entity doesn't have to independently procure something, and when that happens, it makes things a lot easier. And it also creates an interesting opportunity because there may be people working within a state who don't realize that their agencies are even their states are even connected with this. MMCAP actually has some sort of contracting in connection with all 50 states.
Stephanie Krieg 46:23
So sometimes you really just have to think of some practical questions, like: Are we already using this as a state or municipality? Are there public entities that are already participating that we don't even know about in our own state? And where could this infrastructure be useful? Right, if your health department is using it, maybe your state employee health plan doesn't even know about it, or maybe your Department of Insurance doesn't even know it exists. So, really, not working in those silos and connecting. You know, like I mentioned, MMCF just gives that example of government to bring public purchasers together, and that is just one model. So, the next one I'm going to talk about is something that is actually a little closer to me because I'm a steering committee member for this, and that would be ArrayRX. So ArrayRX is a multi-state, publicly governed pharmacy purchasing collaborative. We have several different solutions that ArrayRX is a part of. So we have a prescription drug discount card program, which many of our states on ramp on to start with, as well as prescription voucher programs, workers' compensation, Medicaid, and PBM services. But what's important about RARX isn't just the services that it offers; it's our states and our public entities. But it's how those services are not only created but also governed. So ArrayRX is not just simply commercial products that states purchase off the shelf. We as states help design those strategies. So each solution is grown out of the needs of identified participating states. And as a public mem as a public servant and a member of the steering committee, I actually take part in being able to figure out what the problem is that we're trying to solve, how the strategy could work, what services might be needed, and we work with our we work with our commercial vendors to actually execute these things. So we even, you know, design help design those terms and conditions, the transparency requirements, as well as the accountability and expectations. So states have a seat at the table to make real change and design what they're actually going to be using. So whether we're talking about you know discount cards, vouchers, what have you, government is actually helping to shape the solution rather than just simply buying whatever the commercial market is offering, and that's what's a really exciting thing about ArrayRX. So I like to just kind of highlight a little bit the examples of these different tools, right? And so at the very latest level, because I like to talk a little bit and I'm running low on time, the way that I like to think about MMCAP and a Rarex is like with MM Cap, it's simple. It's as simple as let's procure together, right? Like let's work with the existing infrastructure that we have as an easy on ramp. And with ARXs, let's build and buy differently together. So how can we build this and buy together? And this is the part where I think it's especially important to the broader public pharma conversation because we don't have to perform every function as governments to change our role and how we operate in the marketplace. We can establish a model, we can set expectation and rules, we can use our collective purchasing power. But honestly, you know, there's no one way that will work for every single state, and that's what's really great about these types of models is that it's already existing. And if it's going to work for your state, it's something that's an easy on-ramp to start to think about. So, how do we do this? There's lots of stakeholders and lots of legislators and all different types of people in the room, right? And so I kind of created this flywheel just to really think about how we support one another to not only you know think through how we bring these things into the marketplace, but also think about how we continuously make sure. As someone who's a public servant, like I want to make sure that like we're doing what we say we're going to do by when we say we're going to do it, and making sure that like it's continuously meeting our evolving needs, right? So I advocates they identify those needs. It's so important to have advocates in the room, and I think we can see that as a clear example, right?
Stephanie Krieg 50:30
You can surface problems around affordability. You can bring patient community experiences to the conversation to build momentum and connect people to potential solutions, and then government folks like me who are there to support, like we can, we know what that implementation is going to be like, so we're able to figure out what we're currently buying, how we're going to buy it, who might hold the contracts, and what the actual barrier is to actually join something like these these examples and models highlight, and then that's where we can kind of decide where we either we can't do that or we just haven't done it yet. And then we have our legislators who can then remove those identified barriers. Right. Once we understand the problem and the operational pathway, we then have our legislators to be in such a better position to act because they know what they have to do. Maybe that's enabling legislation, but maybe that's as simple as getting people in the room who don't necessarily talk to each other to know that these things are happening and going on, and working together to make it happen. And then it doesn't stop there. It doesn't stop when you actually implement a program or you implement a solution. You have to constantly be evaluating, and that takes all of us in the room, right? Are people actually using this? Are they addressing the problem that it's intended to solve? Where are people getting stuck? And you know, what are government workers maybe learning operationally, and what are advocates learning from the people who are using it? So that constant evaluation goes around and around to just make sure that programs like this are sustainable and grow, and I think that's a really important thing. So I'm going to stop there. But thank you.
Mara Heneghan 52:14
We might have one more mic that works, but I'm not sure. The before I turn it over to Dana to talk us through distribution, which really ends up being the place where we know if the things we've been able to manufacture or purchase or procure can actually make it to the patients that need those medicines. I want to remind us that we have a Q and A happening in just a few minutes. You should have received note cards when you came in, and for any questions you have, please write those down. And when Dana is done, Chris over here will come collect those note cards, and we will get you as many as we can before we close out tonight. So with that, I will turn it to Dana.
Dana Brown 52:53
Hey everybody, thanks so much for choosing to be here with us tonight. My name is Dana Brown. I'm a public health researcher. I do mostly applied research for policy development at the federal, state, and local level. The municipal level is the most fun, so everybody here get involved in New York City. There's plenty of opportunity to do lots of really cool things right now, and the more of you get that get involved, the easier it is to get them done. I'm going to go off script before I get to my piece and say, by the way, all states should be joining our ARX. It is the fastest piece of a fastest piece of public, fastest growing piece of public pharma infrastructure in the United States. It's free to join, and it's there to serve member states. So I think some states would look and say, "Oh, we've already got a discount card. We don't need that. But it's a place of building public power to counterbalance the power of big pharma. Lots of legislators around the country at various levels sit around complaining about how powerful the healthcare industry is and how we can't do anything to bring down prices. But these guys are doing it, and you can be a part of the solution. And frankly, if bigger, powerful states like New York and California and Texas. If bigger states get involved, there's more that can be done. If you want something done for ArrayRX that you're not seeing yet, join, be a part of the table, and bring those proposals. Right, ArrayRX could be a place that public wholesale distribution comes from, or public manufacturing in a regional sense, or it can be the space where you figure out the problems with you know when one state is going to start doing wholesale distribution or manufacturing. You have the expertise of people around the country who've been dealing with these, who've been troubleshooting problems in the supply chain for decades, and they've been talking to each other. So come and get that knowledge. It's free, which is insane. Okay, right. Most of the things we ask our legislators to do cost money, and getting new appropriations is really hard. This is free. Just do it. So anyway, so we'll add that to to Gustavo Rivera's list. By the way, if you notice, the three pieces of legislation he brought to us today all work with. One another, right? Like manufacturing drugs in the public sector and procuring them more cheaply to begin with would actually make insuring everybody in the state cheaper, right? So there's there's all these public you know benefits and public public partnerships that we could see here, and that's one of the missed opportunities sometimes when we look at each of these things in a siloed way. Okay, so I'm supposed to talk about distribution today. So everybody knows that drugs are too expensive in this country, right? But if you have the money for the prescription that you've been written, you're able to fill it, right? So interestingly enough, in the richest country in the history of the world, even that part of the process breaks down sometimes. The latest statistics say that one in seven Americans-that's over 48 million people-live in what's called a pharmacy desert, right? So they don't have geographic easy access to a pharmacy. That's a little ridiculous. At the same time, independent pharmacies, which are usually our highest quality, the ones that have the most services, that are most responsive to the communities they're in, they're facing an unprecedented wave of closures driven by the low and sometimes below cost reimbursement rates that get pushed on them by pharmacy benefit managers. Closures are happening, of course, at a higher rate in predominantly Black, Latino, and low-income communities, which widen healthcare access gaps for vulnerable populations. This is illustrative of a market failure in what is this last node in the supply chain. So, right, we're the richest country in the history of the world, and we can't even distribute stuff that's too too expensive to begin with. Okay, I've got five minutes. Cities and states can and should step up to fill these gaps. And what you might not know is, historically and internationally, there are lots of presidents. Sweden used to manufacture, develop, and manufacture drugs in the public sector, and then distribute them through all grocery stores.
Dana Brown 56:47
We're talking to folks here in New York and other places about doing similar things. So a friend of mine and I recently published a piece called City Rx, which boldly put some ideas out there about how New York City could both build on the existing public retail pharmacy network that they have and open up new retail locations if needed. Potentially look into mobile and and mail delivery distribution through the public sector, but also do really industrial policy support for independent pharmacies. Right, help leverage the purchasing power of the city, which is gigantic, right? And employs a lot of people and purchases a lot of stuff. Leverage that purchasing power on behalf of all of the small independent pharmacies that want to participate to demand fair rebates and and prices for them, so that we can continue to have the service that we want, and that can be paid for in lots of different ways. But one idea I love is potentially taxing vacant property, like all of those empty Walgreens and Rite Aids that you see around town, because the big guys consolidate and leave, right? And the independents are sticking around to do their job because that's what they believe in. So let's support them. Just want to say that ideas like this are picking up across the nation. In San Francisco, District Supervisor Jackie Fielder has initiated a study that's going to investigate the possibilities for a co-owned and operated pharmacy network, basically a city-backed network of independent pharmacies, where the city, if possible, would be the purchaser again, kind of take on that wholesale, the purchasing and wholesale distribution piece on behalf of the independents who want to join, and the study is also going to look into the the legal and regulatory changes that the city might need to effect effectuate in order to make that possible. At the same time, in Chicago, Alderman William Hall of the Sixth Ward introduced a proposal to combat the growing pharmacy desert problem there. What they're doing is having the city purchase or utilize existing city properties, and they're leasing them but for free to independent pharmacies who will come and utilize the location. So the city is providing the location; they're paying the insurance, they're paying the utilities, and they're having independent pharmacies come in and basically as pop-ups and serve a geographic location where they don't have a fixed retail spot. Eventually, they'd like to have one of these in every ward across Chicago, but they're they're still working on appropriations for that. But the pilot pharmacy just opened back on July 1st, and two different independent existing independent pharmacies are coming in on different days of the week to serve that community there. So I think we see that there's a lot of momentum around the country to solve these problems, and I want to say two things real quick. As as Max and others mentioned, public pharma isn't just about insulin, but insulin is our poster child because it illustrates almost everything that could possibly be wrong with a pharmaceutical supply chain from a human rights point of view, or from a public health point of view, or from a health point of view to begin with. Right? It was said. Originally in a public laboratory over 100 years ago, and then privatized, and has somehow magically managed to still be on patent over 100 years later. Talked to Dahir, Amy, others about that. And it's controlled by an oligopoly of manufacturers, which sometimes decide things like that insulin, even though it serves some patients, we're not going to produce it anymore because we can use our manufacturing space to produce more GLP ones, and those make us more money, right? So it illustrates almost every problem that we can see. There's even distribution issues. Almost every problem we see when it's profits put above patients, and that the idea is public pharma can turn that on its head. The real coup of doing something in the public sector isn't just that it's not for profit. Not profits, nonprofits can do cool stuff too, but in the public sector, you can set a different bottom line. When you create an entity in the public sector, you can say what what is what is the purpose of this? Is it to maximize public health? Right?
Dana Brown 1:01:01
You can create a bottom line that has nothing to do with maximizing profits for anyone, and that is powerful, right? Because if that's our guiding light, we do all of this in a different way, and people like like Stephanie get to do a different job that focuses on meeting people's needs rather than pushing back on corporate power. And I wanted to say to a lot of people in America, look at me and they're like, "That sounds very nice, but we know like you can't do that. Stuff meds are expensive, right? They're really expensive to develop, and so they're going to be expensive to manufacture, and they're going to be expensive to buy always. Well, that's ridiculous because countries that have GDPs like this do it. Cuba manufactures, develops, and manufactures the medications almost entirely fulfills domestic supply on their own, in part by need, right from the embargo. Okay, 10 seconds. Sweden, the UK, Thailand, Brazil, Argentina, et cetera, et cetera. The United States, Massachusetts, Michigan, the Department of Defense. Right. There are hundreds of examples, and we just need to bring that back and make it the new common sense right now. I think there's a growing consensus in this country that's spending a fifth of our GDP on healthcare and not getting much for it's probably a bad deal. Now's the time to kind of drive a truck through that and say we're not going to settle for a tweak here and there for a little change in insurance. We need some changes in insurance, but we we can rethink entire industries like the pharmaceutical industry, which should be there to serve our needs as a country, our healthcare needs as a country, not to serve CEOs and nobody else. So that's what this is all about. Thank you so much for for coming. All
Mara Heneghan 1:02:51
right, can we get our questions to Chris? Wonderful. Yeah, pass them up, pass them down. Thank you all so much, and while Chris is collecting those, I think I will start maybe with a question for Allison about Calorex. So we have Calorex, which is a key example of increased public capacity in public pharma. We've talked about how it's something we're building on in New York, and I'm curious if you can share some lessons. As and we should mention Allison serves on the patient advisory board of Calorex. And I'm just curious if you could share some lessons from the creation and implementation that we can do better in the next go around as we think about New York or other places that are looking to implement similar legislation.
Allison Hardt 1:03:38
Yeah, I'm happy to. I think. Thank you. One of one of the things that we've already kind of touched on is that there's going to be learning involved in any process that you're implementing. So, not to let the fact that there are potential roadblocks or that things have not gone to plan be a reason not to keep trying or to to iterate on it and to have a different implementation, I think that involving people who are most impacted from the beginning is something that we obviously advocate for and became really valuable in the California process, but was a little bit later in terms of how that input was being being collected or heard, and so that is something that we've worked really hard in other states that are looking at policies now to make sure is something that's part of the conversation from the beginning, and that people are in the in the room, those who are most impacted. I think like a kind of classic example was that they were originally going to be producing vials, and one of the reasons that the timeline was a little bit extended on when they could deliver their insulin was because they then found out from talking to people who had diabetes that pens as a delivery method would be the more more highly used, and so that was a different manufacturing process, and that took different contracting and things to be able to get the device actually as well. So, just being able to again like talk to the different stakeholders in the room, I think in in line with that, it's it's super important for for patients, but also with those who are going to be implementing the policy. So knowing that you have talked to your you know the Stephanies in the world, that your departments of health, that the people will actually be tasked with implementing that legislation, it's not just something to design and talk about with as much as we also obviously appreciate the work that the politicians are doing and and that we as advocates can do. The people that actually have to see it through in the day to day it really helps that they're on board and they know what's coming down the pike. So those are a couple.
Mara Heneghan 1:05:39
Thank you. All right. As I'm sorting through, we have one bucket of questions, which is I think generally about where we see the barriers and challenges that we're coming up against and how we're working through those. And so I will maybe ask for whoever wants to kind of jump in there, where as you think about kind of pitching this to the next person, right? And they ask, we've seen these examples you've all talked about. What are the barriers we would name, and how can we say that we've been able to work through them with these initiatives? I'm going to pass. I'm going to send the mic down.
Dana Brown 1:06:14
I'll just say, I mean, for my point of view, is that the biggest barrier is here that it's a mindset, right? Again, we we we assume that there are certain things that are done by private industry in this country, and there are other things that are relegated to the public sector. And again, it just doesn't have to be that way. If the Netherlands, which again is this big, and I've written it down, I don't remember, but the GDP is quite small compared to like the GDP of New York. They're developing and manufacturing bacteriophages in the the public sector. This this is high tech stuff, right? They they see a need, they just do it, right? And that's that's just not the mindset we have about the public sector in this country. But I think we have to challenge that. So part of you know in my conversations with people, I remind them that like the public sector went to the moon, and we worked with our enemies to build the International Space Station, and we kind of built the internet and lithium-ion batteries and some other really cool and important stuff. So actually, we can. We also have developed medications. We have manufactured half of the vaccines on the child vaccination schedule. Now were developed in the interwar period, and wouldn't exist if it weren't for the Department of Defense, which was a major partner and catalyst. So, so part of it, I think, is actually just challenging the way we think about what we can and can't do in the capacity that we have, and sort of using historic and international examples to show that on far more constrained budgets, you know, countries are serving their patients' needs in a different way. And then I think one of the other strategies I love to hear from other folks, though, too, is to look for ways in which some of what we're trying to do meets other needs. So manufacturing, I like to say, it's a jobs program. Public manufacturing is a jobs program. The public sector employs more women and people of color than the private sector, and at greater rates of unionization. These are good jobs. Where do we need good jobs? Oh, in all of the places where the factories have closed, right? Or where we need to phase out a coal. So there's going to be places in the Appalachia that need manufacturing jobs. So thinking about also the different the the different constituencies that we could have on our side, right? It was really cool to work in West Virginia with the unions there when they were about to close the the largest existing the largest remaining generics manufacturing plant in the country. So I think part of it is just is is thinking too about how right this issue and the things that we're asking for are related to all the other issues in this country, right? Affordability is everything right now too.
Stephanie Krieg 1:08:52
I would piggyback off that and just you know, as a health communicator, which is kind of my area of expertise, I think in public health we do a really poor job of explaining to the people in the room what's in it for them, and and well, you know, I think about it from the government perspective, and I have a lot of conversations with governments across the country, especially in my capacity as a steering committee member for IRX, and a lot of times, people come into the room who have just heard about it in in theory, but they may not number one be the right person to be in the room to have the conversation. But then number two, we're not actually speaking to them about what's in it for them. So you know, sometimes we'll be it. I I can only use the state employee health plan as an example as someone who who manages one, but you know sometimes you know for state employees health plan in Connecticut, the comptroller's office manages that program. But in other places, the Department of Insurance or the Treasurer's Office, there's so many different places, and so they have competing priorities all the time. So when you're bringing them in, like for something like procurement. These options already exist that make it super easy for for states to on ramp, but you have to be able to explain it to them in a way that when they leave the room, they not only leave having learned something, but they also leave understanding what's in it for me. So for a state employee health plan, there's in the short term being able to be on have a seat on the steering committee for Rarex. We have a combined over 100 years of pharmaceutical procurement experience in a variety of different ways across all of these states. So to be able to be in the room and have those conversations week over week, you hear about what these other states are doing, and you realize that you can take that back into your own state to do good as well as work collectively, so that's something that's in it for them. Where they leave and they realize, okay, it's great for me to maybe get a discount card program, or maybe I'm interested in a voucher program or PBM services. But also, what's bigger is I have the opportunity to not only learn from other states on a regular basis, but then I also have the opportunity to contribute to the collective national problem that we're already having. So I think that that's been the biggest barrier. And I'd like to say that our steering committee team does a really excellent job of trying to understand what these states' needs are that come to us and highlight that we can help them in the short term, but then we also have solutions for them in the long term as well. So,
Max Goldberg 1:11:22
Yeah, I can speak to just like a New York legislative context a little bit with the Affordable Drug Manufacturing Act, and I think our specific hurdles were just that in our first year, it was really our first year campaigning, and a lot of the work was just too little, too late. In that, Senator Rivera's leadership in the Senate was amazing, and we were included in the Senate's one house, one house budget proposal, which is great, but there was not a lot of work done before us on the Assembly side, and so many of our conversations there in key committees like the Health Committee was just people's first time hearing about it, their first time hearing about CalRecs and their successes, their first time hearing about that the state could even have this capacity, and so a lot of that groundwork was laid last year. I think we are going to capitalize that off of that this year. And then I think we also ran into just in Albany, especially with the the federal landscape. There's an idea. I think that with the amount of stuff coming downstream from Washington, that there's only so much you can do, and you really just have to plug holes, which is understandable because 450,000 people losing health insurance over the summer is a big deal. But I think it is on us then to, in all the ways that we've been talking about, that Dana you spoke about, to show that this is both something that in the long term can be very complementary, and then in the nearest term can help you get with the economic modeling we did showed that the New York State Health Employee Plan would save between seven and $17 million in its first year just by switching members of the plan over to a New York public drug brand insulin that would be at Calorex prices. So that there is like this near term intervention that would also be really critical in helping the state balance the budget in a difficult cycle. So I think there are like very very practical cases that we can make like that, and then again tomorrow's Senator Rivera's framework, we can turn up the heat. And I think there's a lot of ways that we are heading into this session. Some new partners and new coalition members that we're going to use to do that.
Shaina Kasper 1:13:16
I just want to say for barriers, we're also going up against like the biggest industry that the world has ever seen. I'm just like, let's talk about that for a second. There's three pharma lobbyists for every member of Congress. It's just like it's just it's just bonker. Like that's just pharma, right? That's not even looking at the rest of the healthcare industry that does not want to see us to to see success in like having a public option for anything, right? And so we're up against a lot of greed, a lot of profit. To that, that means yeah, we're up against really stiff competition. So just want to name that too.
Mara Heneghan 1:13:55
I heard a wow there, and I'm really grateful that you shared it because that was going to be my contribution if we didn't get there. You all are deep in the work, and we have to think about there's kind of act there's actors working against this, right? I want to kind of stick on barriers for one more minute here, just to ask. And Dana, this will probably be to you, but we had a question about research and development, which we haven't really talked about. Again, we mentioned the scope of the panel is really what we can fit into this amount of time, but I think that that is often something a talking point used about why pharma needs all this money and this investment and why it must be in the private sector, and so I'm just wondering if you can speak. The question is kind of that is often used as the way to argue for the private sector having such a large role here, and I'm wondering kind of for anybody. But Dana, I know you have some work that maybe we want to speak to a little bit here, if you would like.
Dana Brown 1:14:46
Yeah, a couple of things. I'm not gonna. I'm not gonna try to say how much R and D costs because nobody agrees. There are a lot of different numbers out there. Let's just say it's expensive, but. Clearly, medications were developed even before chemicals could be patented, much less drugs, like combinations of chemicals into a drug. So, all over the world, medications were developed and manufactured and utilized before it could be such a profit-making thing. So, I mean, in some ways, that's a counter, you know, example. Just so you know, there is a bill, a federal bill, to do public R and D and to keep the the resulting intellectual property in the public sector and manage it in the public interest. That was introduced by Rashida Tlaib's office with a couple of co-sponsors a few months ago. Unfortunately, overshadowed by the war in Iran, but we hope to reintroduce that and reintroduce it until it passes, because as my friend Adam Gaffney says, public R and D is a cynic one-on of public pharma. It's the top of the supply chain. It's where the decisions get made about what we invest in, and therefore at the bottom, what what can we buy? Why are there so many statins, and you know, no medic, no. Why are we not working on antimicrobial resistance? Because that's what works for the market, and that's not always what's in line with public health. So having a public presence in R and D, like I mean, the state of Texas and the state of California do small scale R and D for in stem cell research, publicly funded, and there are other models like that that focus on a couple of drugs. So, say there are places, especially in Europe, there are many countries that are investing in public R and D in certain subsectors of the market right now: CAR T therapies, other cancer cancer immunotherapies, bacteriophages, as I mentioned, because they're finding it simply too expensive for their health systems to purchase these drugs on the open market, and they're finding that if they're doing it in the public sector, a they're meeting an immediate need, they're doing it at a different cost, but they can also right start to kind of target, create competition in market subsectors. That's that's putting them in a better position vis-a-vis big pharma to negotiate prices, so that's another thing that I always want people to keep in mind. R and D is is costly. I think everybody in the room would probably argue that it's not costly enough to justify the kinds of prices that that we faced. As most people know, there is no statistical relationship between the amount of R and D funds that we know go into the development of any particular drug and the resulting cost. Of course, there is also no cost for any medication. There is a different price for everyone, right? Under every insurance, but every PBM, every blah blah blah, right? So it's all like from an economic standpoint, cost and and price are all are these very fascinating fictions, right? They they segment the market so that we can maximize. Okay, I'm going to give this back because we only have five minutes. But one thing I do want to say real quick, I realize we're probably not going to answer everybody's questions today, but they mean a lot to us. So I want to just say that I would offer to to get answers from this whole group over the next however many weeks, and maybe we can like write a blog or something and send it out with answers. But anyway, we will answer your questions at some point. We'll figure out how to do
Mara Heneghan 1:18:14
it. Yeah, I should have had people write their emails, and you could get a direct follow up from someone. Okay, in the interest of time, I'm going to group a couple together. We have a lot about linking either the various initiatives we've talked about to each other, or linking them to other things like single payer, the bill we've heard in about in New York, linking it to other kind of health justice movements. There's one in here that talks about the international stalemate of the pandemics agreement, and so I'm just thinking if kind of maybe for each person as as our closing question, if you could link the thing you talked about to one other part, either of something somebody else talked about or another part of the health justice movement you're aware of or been a part in. I'm curious where you think we would get the biggest kind of bang for our buck in starting to build those connections. And I will pass it this way, and whoever wants to grab it first can.
Shaina Kasper 1:19:03
You ready? Okay. Yeah.
Allison Hardt 1:19:05
I don't know if I'm answering this, but I I think one of the places, and I hope I'm not stepping on Max's toes here, but I think with like the kind of organizing ecosystem, talking to unions and thinking about labor, and and people that are responsible for negotiating contracts outside of kind of the we've talked a lot about states here, obviously, but there are a lot of, I mean, small business like so many people are are feeling the crunch on on prescription drug prices and on healthcare, and it's the single biggest cost for as a former small business owner. I feel like anyone who's dealing with with this in America is thinking about these costs, and it's only as we've named in the in the coming year is just going to get worse with another double-digit increase of people, like in the cost of the ACA plan premiums and people getting kicked off Medicaid, and it's just it's the pressing concern for people. So.
Max Goldberg 1:20:02
Yeah, I am going to cheat and do a couple things, but I'll do them all very fast. Which is one, seconding what Allison said, and I think in our coalition efforts this year, we've seen labor join us and be excited about this legislation, which is awesome. I think the second thing, just to continue to be the New York guy, what Senator Rivera said about how this act works with the Affordable or with New York Health Act with his Cure Act. I think is is really important to emphasize. There is a chance here for New York to be like the absolute leader across the country in addressing what is really one of the main things people hate about this country, which is their health care. And so I think New York can step up as a leader, and and all those things need to work together, and then the the other one that that Dana was speaking about a little bit, and I say this as someone who's dependent on a medicine that was developed that I need to keep me alive is like bringing the development of those drugs into public hands, so that the science that is so often developed by public institutions, whether it was the NIH or universities with public dollars, whatever stays in the public's interest and can continue to keep me and many other people who are relying on it alive without ever needing to go into pharma's extractive, money-grubbing universe. So, cheating, but those will be the three.
Stephanie Krieg 1:21:17
I think when it comes to procurement and purchasing. I think a lot of it is actually doing coalitions and and policy work like this. It's being able to have different voices in the room that can help you think through different ways of being able to actually acquire and buy and purchase those medications or those services that your that your state or your town or your municipality, whatever it is, can actually do because a lot of the times, again, like I'm sure you all know, government works in a very siloed way. As as someone who works in government, it's frustrating for me too. Sometimes you feel like sometimes you get two steps forward, three steps back, and that bottle of wine is waiting for you at the end of the day in the refrigerator because you feel like you're on a hamster wheel and you only got so much done in a day. However, you know where I see all of the possibility is always like the refreshing conversations I have with groups like this, and the refreshing conversations that I have with states across the country who are trying to solve the same problems. And I know that we always talk a big game about well, they're just conversations, but what's helpful about having the folks who are keeping the trains running on time in the conversation is that we're able to then provide you ideas of how it can work in practice. So I think that'll be helpful.
Dana Brown 1:22:33
I want to work with everyone. I'm currently really excited about the excitement that independent pharmacists are bringing to the table in terms of their problem solving and whatnot, but like big picture federally, I definitely think there's some some serious momentum with the Medicare for All world right now, and I'm very excited about having more conversations and doing more organizing that thinks about you know the mutual benefits of both you know, redoing our insurance system and at the same time, you know, making medications in the public sector, right? And the the way that those two can can serve one another. So yeah, I'm excited about lots of different things, but I think that's kind of in at the moment where some momentum on the federal level is that we can hopefully tap into, and we want to hear all your ideas too. So we'll figure out how to do that somehow.
Shaina Kasper 1:23:33
And I'll just kind of like take take a look up the up the line of like you know follow the money and of just you know why are these drugs so expensive to begin with, and a big part of that reason is patents. And the way our patent system was set up has led to you know just extremely you know all this all this evergreening of our patents of our medicines, the profiteering of these medicines has has been that we aren't able to get the competition in the market that we would like to be seeing, and yeah, again, I think there's a lot of people in this room who are working on that, and that's unfortunately something we can't tackle at the state level. We have to be looking at the federal level, and we know where the solutions are for that right now. But that this is something that there really is could and is looking like there will be momentum and engagement on in in in some in some meaningful ways at the federal level, hopefully by the end of this year, and then you know even just taking a step up from that of just like looking too back at like the the corporate capture of of our governments and of how can we you know change who who you know how how how people are getting influence over our government, you know we've worked on campaigns of you know corporate minimum tax rates and things like that too. These are all just so interconnected, and it's it's wild to think about taxes and talk about manufacturing when we're on a public pharma panel. But that's you know it's all just so interconnected. So. I'm excited to be working on all those things as well as we are. So thanks. Yeah.
Mara Heneghan 1:25:09
There's one more question that I actually have the answer to. Thank you to whoever wrote this, and it says, "When is the next Insulin for All meeting? And since I have the mic, I'm going to say it's Thursday, october 15 at 630 at NYU Law, and you can find Max, who's right here, or Bridget to be added to the WhatsApp group. Thank you, probably Bridget, for writing that card. Can we click one more time? Very, very quickly. I just want folks to know that we have built a public pharma resources page that has much of the work of folks on this panel as well as folks throughout the room here, and the QR code, we will email it out. This is really kind of one of the first things we're able to put out from P3, and hope it can really serve as a resource to the questions we couldn't get through. If we do write a blog from this panel, we'll put it up here as well. But just wanted to make sure we had that. And I think to close us out, I will just say, as our panelists have showed, public pharma is happening, and public power power is essential in the system. Both public power within the government itself, but also public power among patients, providers, folks in this room who are really excited to be kind of moving this forward. And so, I will thank our panelists for helping us get there tonight. The
Announcer 1:26:22
Engelberg Center Live Podcast is a production of the Engelberg Center on Innovation, Law, and Policy at NYU Law, and is released under a Creative Commons Attribution 4.0 International License. Our theme music is by Jessica Batke, and is licensed under a Creative Commons Attribution 4.0 international license.