INTERVIEW: Rep. Mariannette Miller-Meeks’s vision for GOP healthcare reforms: “Put patients in the driver’s seat”

A former physician, Rep. Mariannette Miller-Meeks (R., Iowa) has recently become one of the House GOP’s go-to messengers and policymakers on health care.

Miller-Meeks told the Washington Reporter in an interview that House leadership tapped her for the role, likely because she discussed publicly “the COVID enhanced premium tax credits, the premium tax credits, and the fact that the premium tax credits aren’t going away and that no one was addressing the vast majority of people’s health care costs which are outside of the ACA.”

“You have 20 odd million people in the ACA, about 7 percent of that, you have about 1.6 to 1.7 million, on the enhanced premium tax credits,” she said. “The enhanced premium tax credits were done to hide the fact and shield people from the fact that the Unaffordable Care Act was a failure, and it has never brought down health care costs.”

Her role in the federal healthcare debate is informed by what her constituents are experiencing firsthand.

“There are people whose health care premiums are going up just like mine are going up,” she said. “I’m on the exchange, and like everybody else, my premiums for an individual person are close to $1,000, and they are going up.”

“We haven’t had a lot of people as much as in some other places, but there are people concerned about their premiums going up,” she added. “People not on the exchanges, employers and small businesses, they’re concerned about their premiums going up, and just extending the enhanced premium tax credits does nothing to lower their premiums or lower health care costs. Most people don’t want us to continue subsidizing large insurance companies, and they see the failure of Obamacare to bring costs down…Extending these tax credits, especially enhanced tax credits, does nothing to lower health care costs.”

With full control of the government, Miller-Meeks hopes Republicans can fix problems in the system she said were created by Democrats.

“I was just very honest about talking about what are we going to do to lower health care costs for all of the rest of the people, which is almost half of the population of the United States, and how are we going to fix the failures of Obamacare, rather than just continue to subsidize profitable insurance companies, because the subsidies go directly to them, and then there is no incentive for them to lower premiums and no justification for why premiums are rising,” she said.

Republicans and Democrats differ greatly when it comes to the health care industry, Miller-Meeks added: Republicans favor choice and transparency, while Democrats under former President Joe Biden favored price controls.

“We know that competition works to drive down costs, and it also delivers what patients want,” she said. “Patients want high quality, affordable care. Patients want to be in control of the most personal, intimate aspect of their life, and that is health care for themselves and their families. We’ve already seen what happens when government bureaucrats try to stifle physicians. We saw that happening in real time during COVID, and to only expand that system where patients and doctors have little control over their health care decisions leads to a system where patients feel hopeless.”

“Republicans,” she added, “want to drive down health care costs for everyone, not just a select few. Republicans want to put patients and doctors in the driver’s seat, not profitable insurance companies. We want to put patients and doctors first, and insurance companies are there to provide a service, but not to have all the authority. Extending these tax credits, especially enhanced tax credits, does nothing to lower health care costs.”

Miller-Meeks has also spent years working on reform of pharmacy benefit managers (PBMs), dating back to her time as a legislator in Iowa. Part of her Lower Healthcare Premiums for All Act requires increased transparency in the PBM industry.

In 2019, Miller-Meeks introduced a state-based bill for PBM reform, with mixed results. “I was unable to get 51 percent of the rebate going back to the individual who pays for the drug, but I did get the transparency part through, and even though they were supposed to turn over all of that data to the Insurance Commission within one year, it took over three years, and I have counties that have saved money through just the transparency portion of PBM reform,” she said.

“We know one of the large drivers of increasing healthcare cost is increasing cost of prescription medication. Some of that comes from new drugs, drugs and medication that are personalized, that they’re genetically individualized to people to treat disease,” she said.

“But a lot of it comes from the rapidly escalating and skyrocketing prices of prescription drugs, a lot of which is because of this opaque middleman of the pharmacy benefit manager. They do have some function and role in the drug supply chain, but right now it’s an oversized role. It’s opaque. No one knows what the administrative fees are, or the amount of the rebates, or where those rebates go, and the vertical integration between insurance companies and PBMs is a big deal.”

“At first, PBMs were just contracted to do the drug formularies,” Miller-Meeks noted, surveying the industry.” Then you had insurance companies owning PBMs, and then you had PBMs owning insurance companies. So there was a lot of vertical integration monopoly power, and you have the six largest PBMs doing 90 percent of the prescriptions in the United States, in addition to which, the practices for pharmacies they pay underneath the acquisition cost of a drug, they will claw back after they’ve already paid and say, ‘well, you owe us this,’ and so you have small pharmacies and independent pharmacies going out of business. So all of those actions have made PBM reform for me a priority issue, and I’ve been working on it since I came into Congress in 2021.”

Finally, one of the reforms Miller-Meeks hopes to make to Obamacare is to allow for association health plans again.

“Obamacare, or the Unaffordable Care Act, when it was passed, did away with association health plans,” she said. “They prohibited them, and so the mandates were very much geared towards small insurers, small businesses, self insured individuals. And there was more favorable treatment for the large employers. And so being able to band together, just like a credit union can band together different employees, but in similar industries, to have a larger number of covered lives spreads the risk around, and can lower premiums. And this is anticipated, that it’s one of the things that will help to lower premiums by about 30 percent. It’s very powerful in the effect it can have on lowering health care costs.”

Below is a transcript of our interview with Rep. Mariannette Miller-Meeks, lightly edited for clarity.

Washington Reporter:

Congresswoman, what are you hearing from Iowans about their concerns about health care costs?

Rep. Mariannette Miller-Meeks:

There are people whose health care premiums are going up just like mine are going up. I’m on the exchange, and like everybody else, my premiums for an individual person are close to $1,000, and they are going up. We haven’t had a lot of people as much as in some other places, but there are people concerned about their premiums going up. People not on the exchanges, employers, and small businesses, they’re concerned about their premiums going up, and just extending the enhanced premium tax credits does nothing to lower their premiums or lower health care costs. Most people don’t want us to continue subsidizing large insurance companies, and they see the failure of Obamacare to bring costs down.

Washington Reporter:

How did you become one of the GOP’s go-tos on this issue in the House?

Rep. Mariannette Miller-Meeks:

You would have to ask leadership about that. I would just say that I talked about the enhanced premium tax credits, the premium tax credits, and the fact that the premium tax credits are going away and that no one was addressing the vast majority of people’s health care costs which are outside of the ACA. You have 20 odd million people in the ACA, about 7 percent of that, you have about 1.6 to 1.7 million, on the enhanced premium tax credits. The enhanced premium tax credits were done to hide the fact and shield people from the fact that the Unaffordable Care Act was a failure, and it has never brought down health care costs. So regardless of whether they’re extended, none of it brought down health care costs or premiums for the vast majority of people, and that’s the over 130 million that are on commercial insurance. Between commercial, self-insured, and small businesses, it’s about 164 million people. That’s a lot of people not to do anything to address their health care costs. I was just very honest about talking about what are we going to do to lower health care costs for all of the rest of the people, which is almost half of the population of the United States, and how are we going to fix the failures of Obamacare, rather than just continue to subsidize profitable insurance companies, because the subsidies go directly to them, and then there is no incentive for them to lower premiums and no justification for why premiums are rising. In just talking about that, I guess leadership decided that the things that we have done that will actually bring down health care costs, give individuals more choice, put patients and doctors in the driver’s seat, that I would be a good person to carry that message, but I would ask leadership that question.

Washington Reporter:

One of the bills that you’ve introduced is the Lower Healthcare Premiums for All Act, and one of those features is requiring PBMs to be increasingly transparent. Why is that a priority for you?

Rep. Mariannette Miller-Meeks:

This has been a priority for me for years. When I first entered state government, I was elected as a state senator in 2018 in Iowa, and in 2019 I introduced a bill on PBM reform. I was unable to get 51 percent of the rebate going back to the individual who pays for the drug, but I did get the transparency part through, and even though they were supposed to turn over all of that data to the Insurance Commission within one year, it took over three years, and I have counties that have saved money through just the transparency portion of PBM reform. We know one of the large drivers of increasing healthcare cost is increasing cost of prescription medication. Some of that comes from new drugs, drugs and medication that are personalized, that they’re genetically individualized to people to treat disease. But a lot of it comes from the rapidly escalating and skyrocketing prices of prescription drugs, a lot of which is because of this opaque middleman of the pharmacy benefit manager. They do have some function and role in the drug supply chain, but right now it’s an oversized role. It’s opaque. No one knows what the administrative fees are, or the amount of the rebates, or where those rebates go, and the vertical integration between insurance companies and PBMs is a big deal. At first, PBMs were just contracted to do the drug formularies. Then you had insurance companies owning PBMs, and then you had PBMs owning insurance companies. So there was a lot of vertical integration monopoly power, and you have the six largest PBMs doing 90 percent of the prescriptions in the United States, in addition to which, the practices for pharmacies they pay underneath the acquisition cost of a drug, they will claw back after they’ve already paid and say, ‘well, you owe us this,’ and so you have small pharmacies and independent pharmacies going out of business. So all of those actions have made PBM reform for me a priority issue, and I’ve been working on it since I came into Congress in 2021.

Washington Reporter:

One of the other parts of your bill is allowing workers to band together to purchase association health plans. Do you see more options resulting in lower premiums?

Rep. Mariannette Miller-Meeks:

One-hundred percent. We know that Obamacare, or the Unaffordable Care Act, when it was passed, did away with association health plans. They prohibited them, and so the mandates were very much geared towards small insurers, small businesses, self insured individuals. And there was more favorable treatment for the large employers. And so being able to band together, just like a credit union can band together different employees, but in similar industries, to have a larger number of covered lives spreads the risk around, and can lower premiums. And this is anticipated, that it’s one of the things that will help to lower premiums by about 30 percent. It’s very powerful in the effect it can have on lowering health care costs.

Washington Reporter:

Under the Biden administration, you voted against the Democrats’ price controls on prescription drugs and increased regulations for doctors. Can you talk about why your approach of more choice and transparency that you just laid out is more effective than the Democrats’ moves for price control and increased regulation?

Rep. Mariannette Miller-Meeks:

We know that competition works to drive down costs, and it also delivers what patients want. Patients want high quality, affordable care. Patients want to be in control of the most personal, intimate aspect of their life, and that is health care for themselves and their families. We’ve already seen what happens when government bureaucrats try to stifle physicians. We saw that happening in real time during COVID, and to only expand that system where patients and doctors have little control over their health care decisions leads to a system where patients feel hopeless. And I will repeat, Republicans want to drive down health care costs for everyone, not just a select few. Republicans want to put patients and doctors in the driver’s seat, not profitable insurance companies. We want to put patients and doctors first, and insurance companies are there to provide a service, but not to have all the authority. Extending these tax credits, especially enhanced tax credits, does nothing to lower health care costs.

Washington Reporter:

Finally, where are you spending New Year’s Eve?

Rep. Mariannette Miller-Meeks:

Probably in Iowa, at home by a fire.

Washington Reporter:

Thanks congresswoman.