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There’s a good chance you’re overpaying for medication

New policy lets worst offenders behind high drug prices off the hook

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(Photo by Vitalii Petrushenko/Bigstock)

In its push to lower the cost of medicine, Congress has focused on giving Medicare the authority to negotiate drug prices with manufacturers. Officials just announced the first 10 medicines up for negotiation under the Inflation Reduction Act (IRA).

Unfortunately, all of the attention given to that policy lets some of the worst offenders behind high drug prices off the hook: pharmacy benefit managers, or PBMs — companies that function as powerful drug-industry middlemen.

Acting on behalf of insurers, PBMs use their buying clout to obtain discounts and rebates from drug makers. In theory, these savings should be passed on to patients at the pharmacy counter. But in fact, while PBMs extract billions of dollars in profit for themselves each year, patients see little to no benefit.

It’s time to change this system. Thankfully, lawmakers now have PBMs in their sights in a proposed bipartisan reform bill.

The fundamental problem is that PBMs wield enormous influence over drug prices, with virtually no transparency or accountability. They’re able to wield such power because they control insurance company formularies — those lists that determine which drugs your insurer will cover, and on what terms.

PBMs have drug manufacturers over a barrel because (in a helpless position), in order to make sufficient sales, the manufacturers need their products on formularies on favorable terms. But even though PBMs are charged with obtaining discounts, their interests are not aligned with those of patients. In fact, just the opposite is true.

The PBM revenue model is linked to the list prices of drugs. The higher the list price, the bigger the discount they can obtain. That means that PBMs make more money off more expensive medicines, giving them a perverse incentive to offer better formulary placement to pricier treatments. But that, in turn, pressures drug makers to increase list prices, on the expectation of offering larger discounts.

Meanwhile, the coinsurance obligations that patients pay continue to be calculated based on list prices — not the discounted prices insurers actually pay. By exploiting this difference, PBMs manage to charge two-thirds of patients for the full list price of a drug, even though they’ve negotiated deep discounts from the manufacturer.

Mergers and acquisitions among PBMs and insurers have given them even more power. Currently, just three PBMs make up 80% of the prescription drug market, and the top six control nearly the entirety, 96%. At the same time, the three biggest PBMs either own or are owned by the three biggest insurance companies. They also use their sway to steer patients to fill prescriptions at the pharmacies they likewise own.

Consider how this whole setup affects patients with HIV. While there are more than 30 FDA-approved medicines to treat the virus, a PBM can steer patients toward the most expensive options via their insurance coverage. Then, a patient can be required to pay a percentage of the list price out of pocket, rather than a percentage of the lower price the insurer actually paid.

There’s still more in the PBM-insurer bag of tricks. Drug makers often issue discount coupons to help patients with coinsurance requirements. But PBMs and insurers essentially steal the value of those coupons right back, by refusing to count them toward deductibles and annual caps on out-of-pocket spending.

Insurers and their PBMs are also behind the “utilization management” rules that patients increasingly face when seeking care. So-called “prior authorization” policies, for instance, require doctors to ask insurers’ permission before ordering certain drugs or tests. Such policies have been an obstacle to patients obtaining PrEP drugs, the pre-exposure prophylaxis that prevents HIV transmission.

As so many activists and lawmakers have observed, we need to bring down out-of-pocket medication costs. One-third of Americans report not filling a prescription because of price, and we know that when prescription costs increase, patients are less likely to adhere to their medication regimen. Their health suffers as a result, often requiring additional interventions and hospital stays.

But the new IRA plan for drug-price negotiations can’t solve all these problems. Lawmakers also need to rein in PBMs. Specifically, any new legislation should decouple PBM compensation from the list prices of drugs, so that the companies aren’t motivated to steer patients toward the most expensive treatments.

For the sake of patients, myself included, there’s no time to lose.

Guy Anthony is president and CEO of Black, Gifted & Whole.

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Why trans suffering is more palatable than trans ambition

We are most readily accepted when framed as victims

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(Photo by nito/Bigstock)

In the current media and political climate, stories of trans suffering move quickly. Stories of trans ambition do not.

A trans teenager denied healthcare. A trans woman attacked on public transit. A trans man struggling with homelessness. These narratives circulate widely, often accompanied by solemn op-eds, viral posts, and carefully worded statements of concern. The pain is real. The coverage is necessary. But there is a quieter pattern beneath it: trans people are most readily accepted when they are framed as victims—and most resisted when they present themselves as agents with desire, confidence, and upward momentum.

This distinction has sharpened in recent years. As anti-trans legislation has proliferated across statehouses and election cycles have turned trans lives into talking points, the public script has narrowed. Trans people are legible as objects of harm, but far less comfortable to many audiences as subjects of ambition. Survival is tolerated. Aspiration is destabilizing.

The reason suffering travels more easily is not mysterious. Pain reassures the audience. It positions trans people as recipients of concern rather than participants in competition. A suffering subject does not threaten status hierarchies; they confirm them. Sympathy can be extended without requiring a recalibration of power, space, or expectations. In this framing, acceptance remains conditional and charitable.

Ambition disrupts that arrangement. A trans person who wants more than safety—who wants money, authority, visibility, creative control, or institutional influence—forces a different reckoning. Ambition implies permanence. It implies entitlement. It implies that trans people are not passing through society’s margins but intend to occupy its center alongside everyone else.

You can see this discomfort play out in real time. When trans people speak about wanting success rather than safety, the response often shifts. Confidence is scrutinized. Assertiveness is reframed as arrogance. Desire is recoded as delusion. The language changes quickly: “unstable,” “narcissistic,” “out of touch,” “ungrateful.” In public discourse, confidence in trans people is frequently treated not as a strength, but as a warning sign.

Media narratives reinforce this dynamic. Even ostensibly positive coverage often relies on redemption arcs that center suffering first and ambition second—if at all. Success is framed as overcoming transness rather than inhabiting it. A trans person can be praised for resilience, but rarely for dominance, excellence, or command. Achievement must be softened, contextualized, and made reassuring.

This is especially visible in cultural reactions to trans people who refuse modesty. Trans figures who express sexual confidence, professional competitiveness, or political authority routinely face backlash that their cis counterparts do not. They are accused of being “too much,” of asking for too much space, of wanting too much too fast. The underlying anxiety is not about tone; it is about proximity. Ambition collapses the safe distance between observer and observed.

Politically, this preference for suffering over ambition is costly. Movements anchored primarily in pain narratives struggle to articulate futures beyond harm reduction. They mobilize sympathy but have difficulty sustaining leadership. A politics that can only argue from injury is perpetually reactive, always responding to the next threat rather than shaping the terrain itself.

This matters in a moment when trans rights are no longer debated only in cultural terms but in administrative, legal, and economic ones. Influence now depends on institutional literacy, long-term strategy, and the willingness to occupy decision-making spaces that were never designed with trans people in mind. Ambition is not a luxury; it is a prerequisite for durability.

Yet ambition remains suspect. Trans people are encouraged to be grateful rather than demanding, visible rather than powerful, resilient rather than authoritative. Even within progressive spaces, there is often an unspoken expectation that trans people justify their presence through pain rather than through competence or vision.

This is not liberation. It is containment.

A society that can tolerate trans suffering but recoils at trans ambition is not offering equality; it is managing discomfort. It is willing to mourn trans deaths but uneasy about trans dominance, trans leadership, or trans desire that does not ask permission. It prefers trans people as evidence of harm rather than as evidence of possibility.

None of this is an argument against documenting suffering. That work remains essential, particularly as legal protections erode and violence persists. But suffering cannot be the only admissible register of trans life. A politics that cannot imagine trans people as ambitious cannot sustain trans people as free.

Ambition does not negate vulnerability. Desire does not erase harm. Wanting more than survival is not ingratitude—it is the baseline condition of citizenship. The question is not whether trans people deserve ambition. The question is why it remains so unsettling when they claim it.

Until that discomfort is confronted, acceptance will remain conditional. Sympathy will remain cheap. And trans futures will continue to be negotiated on terms that stop just short of power.


Isaac Amend is a writer based in the D.C. area. He is a transgender man and was featured in National Geographic’s ‘Gender Revolution’ documentary. He serves on the board of the LGBT Democrats of Virginia. Contact him on Instagram at @isaacamend

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Snow, ice, and politics: what is (and isn’t) happening

Let the National Guard dig us out

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17th Street, N.W., in Dupont Circle on Jan. 26, 2026, after Winter Storm Fern dumped upwards of 7" of snow and sleet on the city. (Washington Blade photo by Michael K. Lavers)

First what isn’t. That would be snow removal in D.C. I understand the inches of sleet that fell on the nearly four inches of snow, and historic days of freezing weather, make it very difficult. But it took three days until they brought out the bigger equipment. Then businesses and homeowners were told they wouldn’t be fined for not clearing their sidewalks, which they have to do by law. That clearly made things worse. The elderly and disabled have an exemption from that, others shouldn’t be given one. Then there was no focus on crosswalks, so pedestrians couldn’t get around, and no apparent early coordination with the BIDS. 

Then there are about 2,200 National Guard troops strolling D.C., yes strolling, at least before the snow. Why weren’t they given immediate snow removal duty. If the president gave a damn about our city he would have assigned them all to help dig out the city. We could have used their equipment, handed out shovels, and put the Guard to use immediately. Maybe the mayor put in her request for the Guard a little late. 

I have met and chatted with many Guard members across the city. A group from Indiana regularly come to my coffee shop, though I haven’t seen them since the snow. I always thank them for their service — I just wish it wasn’t here. Nearly all agree with me, saying they would rather be home with their families, at jobs, or in school. I’ve met Guard members from D.C., West Virginia, Indiana, Mississippi, and Louisiana. My most poignant meeting was with one Guard member from West Virginia the day after his fellow Guard member was murdered. Incredibly sad, but avoidable; she should never have been assigned here to begin with. The government estimates it costs taxpayers $95,000 a year for each deployment. So, again, instead of strolling the streets, they should have been immediately assigned to assist with snow removal. Clearly the felon, his fascist aides, and incompetent Cabinet, are too busy supporting the killing of American citizens in Minneapolis, to care about this. I thank those Guard members now helping nearly a week after the snow began to fall. I recognize this was a difficult storm. I hope the city will learn from this for the future. 

Now for something happening in D.C. that shouldn’t be. A host of retreads have announced they are candidates for office in both the June Democratic primary, and general election. Some are names you might remember but hoped were long gone. Two left the Council under ethical clouds. One is Jack Evans. He announced his candidacy for City Council president. I like Jack personally, having known him since he served on a Dupont ANC. This race is a massive waste of time and money, as he will surely lose. Even before his ethics issues were made public, and his leaving the Council under a cloud in 2020, he ran for mayor in 2014. At that time, he received only 5% of the vote, even in his own Ward. At 73, he should accept his electoral career is over. Another person who left the Council over questionable ethics, Vincent Orange, who is nearly 70, announced he is running for mayor. He did that last in 2014, when he got only 2% of the vote in the primary. He is another one who will surely lose. Both will likely qualify for city funding, wasting taxpayer money. I know I will be called an ageist. But reality is, in most cases, it’s time for a new generation to take the lead. Another person who has served before, was defeated for reelection, is now trying for a comeback on the Council. I think the outsized egos of these individuals should not be foisted on the voters. If they are really interested in serving the community, there are many ways to do it without holding elective office.

Then there is ICE and the continuing situation in Minneapolis. I applaud Democrats in Congress for holding up long-term funding for ICE for at least two weeks and getting the felon to negotiate. Now not every ICE agent behaves like the gestapo, but their bosses condone the behavior of the ones who do. Secretary of Homeland Security, Kristi Noem, who shot her dog, and Trump’s Goebbels, Stephen Miller, seem to think nothing of causing the deaths of American citizens. 

Now the felon’s FBI and DOJ are arresting journalists; then going to Georgia and removing stored ballots from the 2020 election, all because the felon is still obsessed with that loss. His disappearing DNI, Tulsi Gabbard, was involved in that for some reason. The felon is a sick, demented, old man. They must all be stopped before they completely destroy our democracy.


Peter Rosenstein is a longtime LGBTQ rights and Democratic Party activist.

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Confuse Iceland and Greenland, you’re an idiot

Insult your allies, you’re a dangerous fool

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President Donald Trump speaks at the World Economic Forum in Davos, Switzerland on Jan. 21. (Screen capture via The Wall Street Journal/YouTube)

Some people excuse the sick felon in the White House for confusing Iceland and Greenland, after all, they are both cold. Actually, he is a senile old fool, and people must consider whether he should be locked up and kept out of trouble. The only problem with that is J.D. Vance. He could be worse, because however disgusting, he is smarter. After all, he once compared Trump to Hitler. 

The felon creates problems and then thinks when he backtracks on what he said or did, he should get credit for solving the problem he created. Recently the stock market plummeted 800 points in one day, based on the stupid things he said about attacking Greenland and imposing tariffs on our allies. When he changed his mind and backtracked, he took credit for the market going up. In some ways it simply looks like insider trading, when his friends and family knew what he was going to do. To others, it is simply a ploy to get Epstein off the front pages, and based on our media not doing their job, it’s working. 

His speech in Davos was totally embarrassing. Joe Biden clearly lives in his head since he defeated him in 2020. He apparently blames Biden for the fact that during Biden’s presidency, Trump was charged and convicted of various crimes including 34 felonies. 

He recently told the New York Times he can do anything he wants as president, as long as it doesn’t conflict with his own morality.  Since he has none, he believes he can do anything. Now we see being King of the United States is not enough; he wants to be an emperor. Hence his formation of the ‘Board of Peace.’ Simply another way of grifting, as he is asking for a billion dollars from each member, and there are no obvious controls on the money. It will not be a success, again except for his looting it, when you look at who signed up to join this organization. Members include: three ex-Soviet apparatchiks, two military-backed regimes, and a leader sought by the International Criminal Court for alleged war crimes, with only two EU countries, Bulgaria and Viktor Orban’s Hungary, according to the Financial Times. 

Then on his way out the door from Davos, he made the United States, and himself, look even worse, when as reported by CBS news, “President Trump claimed the U.S. had ‘never needed’ its NATO allies, and that allied troops had stayed ‘a little off the front lines’ during the 20-year war in Afghanistan.” This was entirely untrue and actually, “The only time NATO has ever enacted Article 5 was after the 9-11 terrorist attacks on the United States, and the world rallied to the support of the U.S.,” Alistair Carns, the U.K. government’s Minister of the Armed Forces and a veteran who served five tours in Afghanistan alongside American troops, said in a video posted Friday on social media. “We shed blood, sweat and tears together, and not everybody came home. These are bonds, I think, forged in fire, protecting U.S. or shared interests, but actually protecting democracy overall.” 

More than 2,200 American troops were killed in Afghanistan, according to the Pentagon. The Reuters news agency says 457 British military personnel, 150 Canadians and 90 French troops died alongside them. Denmark lost 44 troops in Afghanistan — in per capita terms, about the same death rate as that of the United States.” 

“Lucy Aldridge, the mother of the youngest British soldier killed in Afghanistan, told the BBC she was “deeply disgusted” by Mr. Trump’s comments. Her son William Aldridge was only 18 years old when he was killed in a 2009 bomb blast, while trying to save fellow troops.”

We are being represented on the world stage by a sick, evil, blathering idiot, who has no idea of history, no morality, and no decency. He was called out on this by the prime minister of the U.K., Keir Starmer, who normally appears to play up to the felon, when he called the remarks “insulting and frankly appalling.” He went on to say, “We expect an apology for this statement. Trump has “crossed a red line’, we paid with blood for this alliance. We truly sacrificed our own lives.”

Every day Trump slides more into the sewer, spreading hate, and violence, both here at home, and around the world. If there are any decent people left around him, unfortunately there may be none, for the good of humanity, they must stop him. 


Peter Rosenstein is a longtime LGBTQ rights and Democratic Party activist.

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