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COLUMBUS -- As Ohio debated whether to require Medicaid and other insurers to cover new, higher priced prescription painkillers, records show pharmaceutical lobbyists pushed officials to lower their estimates of what it would cost the state.
Three fiscal analyses were prepared on legislation that sought to expand patient access to so-called abuse-deterrent opioids considered harder to manipulate and therefore abuse. The industry is pushing the new painkiller formulations nationally as a key solution to America's opioid crisis.
Though House Bill 248 died in December, the National Conference of State Legislatures says 16 bills in 10 states that relate to abuse-deterrent opioids have been introduced since the start of 2017. The industry continues to push these medications despite little proof the reformulated opioids reduce drug abuse or death.
The estimated taxpayer cost of the Ohio proposal was adjusted significantly down over seven months as lobbyists worked behind the scenes to influence lawmakers and analysts, according to legislative documents and emails obtained by The Associated Press through a public records request. A new state budget cycle was approaching at the time, and all lobbyists know the less a policy change costs the more likely lawmakers will support it.
An October 2015 fiscal note estimated that replacing 5 percent of Medicaid prescriptions for painkillers with higher-priced abuse-deterrent versions would cost the state between $11.2 million and $167 million a year. In April 2016, legislative analysts said replacing twice that percentage would cost the program just $2.8 million a year.
The bill had been rewritten in between the two financial assessments, but the competing estimates involved the same factors: Replacement of a percentage of Ohio Medicaid recipients' existing painkiller prescriptions with abuse-deterrent alternatives. The four federally approved formulations at the time were for Oxycontin, Embeda, Hysingla ER and Targiniq ER.
Lobbyists for drugmakers including Pfizer, Purdue Pharma and Teva Pharmaceuticals sought to drive down the estimate even further, emails show.
"We believe a more true cost for every 10% uptake (sic) of use is more likely $400,000," Pfizer lobbyist Matt Whitehead wrote in an Aug. 31, 2016, email to state Rep. Robert Sprague, the bill's Republican sponsor, after the $2.8 million figure was released.
Whitehead told Sprague that analysts neglected to factor in price rebates of 23 percent for brand drugs and 13 percent for generics, federal medical assistance percentages that affect state matching grants and Consumer Price Index penalties that protect states from price spikes. The $2.8 million estimate remained in the third fiscal analysis, issued a month later.
State Rep. Nickie Antonio, the bill's Democratic sponsor, said the big drop from the highest to the lowest estimate may have been a result of optimistic thinking. She said during the time between the two estimates, Ohio was working aggressively to reduce overall prescription rates for opioid painkillers.
"A lot less was being prescribed and maybe the anticipation was opioid prescriptions would keep going down," she said.
An AP investigation last year found pharmaceutical companies and allied groups belonging to the Pain Care Forum gave roughly $6 million to Ohio campaigns -- more than $3.5 million at the state level and nearly $2.5 million at the federal level -- from 2006 through 2015.
Tom Brownlie, Pfizer's director of U.S. policy, argued during testimony on the Ohio bill that, in assessing the financial impact of either requiring or allowing abuse-deterrent opioids, state lawmakers needed to assess cost and savings "holistically, rather than focusing on one part of the equation."
The estimate that the initial version of the bill would cost Ohio's Medicaid program between $11.2 million and $167 million for each 5 percent of standard opioids that were replaced with the abuse-deterrent variety came directly from the state.
Jenelle Donovan Lyle, legislative director for the Ohio Department of Medicaid, provided the figures to legislative analyst Justin Pinsker in an Oct. 6, 2015, email, records show. She told Pinsker the percentage of current prescriptions that might be replaced with abuse-deterrent drugs was an "unknown factor" and that if it turned out to be 15 percent, costs to the state could go as high as between $33.7 million and $501 million.
Donovan Lyle said costs were high because no generics existed yet for abuse-deterrents and because, without controls, history showed that "utilization will increase greatly."
The administration lobbyist cautioned that the new generation formulations don't actually prevent addiction.
She wrote: "These just prevent a person from crushing the pill and injecting the powder; people still can and do take it orally and get addicted."