Drug Pricing Dishonesty Pharmacies and insurance companies are passing on costs to consumers, but we’re not talking about it.

Straight talk and honesty are valued in my home state of West Virginia. Between neighbors, teachers and parents, companies and unions, or politicians and their constituents, we value frank and open conversation instead of muddled half-truths. With the election year approaching, sifting through the many distortions and angles is a full-time job. For the hot-button issue of health care, straight talk couldn’t be more important, but sadly, that’s not what we’re getting.

Public health is a serious issue for all of America, but particularly in West Virginia. Our citizens are by and large older and more rural than much of the rest of America. Many are hardworking laborers and coal miners or live on fixed incomes through Social Security and other federal and state safety net programs. Chronic disease is a particular problem in our state, and thousands suffer from diabetes, heart disease and hypertension. Pulmonary illnesses affected one-fifth of all West Virginians in 2003, some as a direct result of decades of work in the coal mines. As would be expected, prescription drug treatments are necessary for the many illnesses that these patients face – one study found that West Virginia was 59 percent above the U.S. average for prescription drug cost burden.

All of this brings the national drug pricing debate to our backyard. From the mouths of mayors and city councilmen, all the way to presidential candidates, drug companies have become a public whipping post as public figures seek to assign blame for high prescription drug costs. Yet this criticism actually bypasses the real root of the problem.

When it comes to health care costs, most Americans don’t know there are a number of players, including the insurance companies and pharmacy benefits managers that serve as middlemen in the health care field and determine what costs will be passed on to patients. Ignoring their role in the ongoing drug pricing debate is a mistake.

More and more, insurance companies, pharmacy benefit managers and pharmacies themselves are passing costs directly to consumers. For instance, these middlemen have instituted cost-sharing tiers that push a bigger and bigger percentage of a drug’s cost to patients. The insurance companies also do consumers a disadvantage by putting only certain drugs on their formularies, the list of drugs they agree to approve. These lists are chosen by committees that don’t reveal to consumers their criteria for choosing one drug over another and often leave breakthrough drugs off the list.

Their actions mean we’re seeing rising copays for consumers, which is understandably sparking consumer outrage. In Kentucky, a movement called Cap the Copay is underway, and similar groups have cropped up around the country. Insurance companies are rapidly consolidating – there remain only five major insurers left in the entire United States – and as competition shrinks, their growing clout may put much-needed drugs out of the hands of working-class customers.

[READ: Wall Street Demands Are Driving Up Drug Prices]

Pharmacies are consolidating too, and absorbing pharmacy benefit managers at a rapid pace. Walgreens announced a deal to buy Rite Aid, and CVS is taking over the pharmacies in Target stores. As with the insurers, less competition leads to higher prices for consumers. In West Virginia, we know that big pharmacies haven’t been the most consumer-friendly businesses. They took single-ingredient pseudoephedrine, which is used to make crystal meth, off their shelves, but only after a long, protracted public campaign.

In recent years, there has been a push to look at patient care more holistically, but taking that approach to health care shouldn’t stop in the exam room; it’s an attitude that also needs to be adopted in health care policy discussions, from board rooms to the halls of Congress and to the media’s analysis of the problem.

No one understands this better than me. The need for effective treatments is desperate in southwest West Virginia and northeast Kentucky. When I co-chaired the House Prescription Drug Caucus, along with Republican Rep. Hal Rogers from Kentucky, we were focused on looking at the issue with a wide and honest lens. The role of insurance companies and pharmacy benefit managers are being left out of the conversation on drug prices today, and that’s an issue of real concern.

There is no doubt health care policy will continue to be front and center leading up to the 2016 elections, and rising health care costs and reduced accessibility for consumers should be a focus for all candidates. But as discussions heat up, we need straight talk, and this requires looking at our nation’s health care system in its entirety, not just cherry-picking one issue or industry to grab headlines. Americans have suffered enough dishonest debate when it comes to health care. More of the same will only hurt where we need help the most.

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Nick Rahall is a former U.S. representative for West Virginia, where he served as ranking member of the Transportation and Infrastructure Committee and was co-chair of the bipartisan Prescription Drug Caucus.

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