When President Donald Trump accused community health clinics of charging poor patients high prices for insulin and Epi-Pens at a White House event on Friday, Sue Veer could hardly believe her ears.
"I won't use the language I used sitting in front of the television," said Veer, who serves as President and CEO of Carolina Health Centers. "This is being put out there to fix a problem that doesn't exist."
An executive order Trump signed Friday targeted drug discounts that Federally Qualified Health Centers receive and reinvest in community services. The executive order proposes withholding future grant funds from community clinics unless they charge low-income patients the acquisition price for insulin and Epi-Pens, plus an administration fee. The policy comes as FQHCs have served vulnerable populations by providing COVID-19 testing and other services on the front lines of the pandemic.
Community health clinics said they were blindsided by the policy and already provide drugs to low-income patients at low cost.
"My analogy is that they are looking at the tiny tail of the elephant, and missed the elephant reality of what 340B is," said NACHC senior policy adviser Colleen Meiman.
While GOP lawmakers have expressed concern about the expansion of the 340B drug discount program, their complaints have generally centered around hospitals, not community health clinics. FQHCs are statutorily required to reinvest any savings from 340B in community services, a standard that does not apply to hospitals.
Even critics of the 340B policy were taken aback by the order's focus on community clinics at the exclusion of hospitals or other covered entities.
"I generally consider these covered entities to be the good guys of 340B," wrote Drug Channels Institute founder Adam Fein. "Notably, the executive order doesn't mention hospitals, which are the worst abusers of the 340B program."
HRSA Administrator Tom Engels on Wednesday praised community health centers for their work serving vulnerable patients during a virtual appearance at the 340B Coalition's summer conference. The National Association of Community Health Centers said 91% of the patients clinics serve nationwide earn below 200% of the federal poverty line according to 2018 data.
Just two days after the conference appearance, Trump claimed community health centers were pocketing discounts.
"These providers should not be receiving discounts for themselves while charging their poorest patients massive, full prices," Trump said.
Community health centers' payment policies for drugs vary from clinic to clinic, so there's a chance some existing health center clients could see somewhat lower cost-sharing obligations. Vee said it seems like the order, if implemented, would have minimal financial impact if it is limited to low-income patients, as FQHCs already provide patients with discounts.
"What I am far more concerned about the potential impact of mischaracterizing the integrity of the community health center 340B program," Vee said.
The executive order text was fairly vague, and it isn't clear how the policy could impact arrangements with contract pharmacies that have drawn scrutiny for their revenues from the 340B program, or who exactly would be covered by the pricing requirements.
Rena Conti, an associate professor at Boston University who has studied the 340B program, said community health centers have to meet more stringent reporting standards about their outpatient patient populations compared with hospitals. Conti wasn't surprised that hospitals were excluded from the election-year batch of orders.
"That would have poke a very serious and disciplined enemy in a time when these institutions are financially struggling," she said.
State lawmakers in Connecticut are, in contrast to the White House, looking at potentially driving more patients to FQHCs to get affordable insulin. State lawmakers on Tuesday were set to vote on a bill that would establish a commission to consider whether to refer patients with diabetes to FQHCs regardless if they have health coverage.
The federal executive order would have little impact in Los Angeles because of existing coverage and discount programs available to low-income people, said Community Clinic Association of Los Angeles President and CEO Louise McCarthy. If the administration was concerned about contract pharmacies' 340B revenue, McCarthy said they should have targeted the order more narrowly.
"We are going to try to figure out where this came from and who did we tick off, that they decided to go after the little guys," McCarthy said.