ST. CHARLES, Mo. — Claire McCaskill is betting her political future on a simple hope: that Missouri voters care enough about drug pricing to give her another term in Washington.
It is a bold strategy for a Democrat in an increasingly red state, facing an uphill battle to keep her Senate seat. Yet McCaskill is investing heavily in the approach, devoting fully half of a 15-minute stump speech here last week to the perceived evils of pharmaceutical manufacturers.
“I think people are more angry today than they’ve ever been about how they’re being taken for a ride with the increase in pharmaceutical drug prices,” she told STAT on Friday, after a rally at a local Democratic Party office in this St. Louis suburb. “I think it is an issue that is more motivating than almost any other issue I talk about in this campaign.”
If the response from her partisans is any indication, her theory seems sound. Early in her appearance before roughly 100 supporters, McCaskill announced what would be her top priority should Missouri send her back to Washington: allowing Medicare to negotiate drug prices with manufacturers.
The crowd roared.
The Democratic Party has largely squandered an opportunity to make high pharmaceutical costs a signature campaign issue, despite polling that suggests health care and drug costs are top priorities for voters.
But McCaskill is an exception. In contrast to party leaders whose campaigns are funded in large part by the pharmaceutical industry, she is speaking about drug manufacturers in an uncommonly aggressive tone: using the pejorative term “Big Pharma” and telling voters in a TV ad that “pharmaceutical companies are using the law to feed their greed.”
Meanwhile, McCaskill’s opponent — the state’s attorney general, Josh Hawley — is playing defense on health care. Hawley is among the named plaintiffs on the lawsuit to overturn the Affordable Care Act, and with it, protections for individuals with pre-existing health conditions. But despite the lawsuit, or perhaps because of it, Hawley has not made health care a key pillar of his campaign.
As much as McCaskill seems to relish skewering Hawley over his topsy-turvy health care record, she seems to relish her verbal beating of drug companies more.
“What we see in our polling is that voters perceive the issue of high drug costs very much in the context of corporate greed,” said Geoff Garin, the president of Hart Research, a progressive polling firm. “They want elected officials like Claire McCaskill to have the independence and courage to stand up to Big Pharma.”
Among the many vulnerable Democrats up for re-election, McCaskill poses perhaps the largest looming threat for the drug industry. Already, she has built a resume as an anti-pharma crusader while focusing on two nationwide crises she says the drug industry is largely responsible for: high prescription drug costs and the opioid crisis.
As the highest-ranking Democrat on the Senate Homeland Security and Governmental Affairs Committee, McCaskill has already taken drug manufacturers and distributors to task for what she views as unjustifiable price increases and for their roles in the opioid crisis.
If her party takes the Senate either this year or in 2020, she would likely chair the committee, giving her broad flexibility to conduct oversight on any company or industry she sees fit as well as a tool that has become McCaskill’s white whale: subpoena power.
“Yeah,” said one lobbyist for a major drug manufacturer, who spoke on the condition of anonymity. “She’d be a problem if she were put back.”
McCaskill has plenty to say about the drug industry — and has found that Missouri voters are content to hear pharma-bashing at almost any level of specificity.
“Do all of you know what the donut hole is?” McCaskill asked a crowd of mostly seniors in Columbia, referring to the coverage gap that puts Medicare beneficiaries on the hook for drug costs above $2,700 per year, before catastrophic coverage kicks in.
The room bobbed up and down, as heads of white hair, gray hair, and no hair at all nodded as one.
In St. Charles, McCaskill advocated for a wholesale ban on pharmaceutical TV ads, complaining that only the U.S. and New Zealand allow direct-to-consumer drug marketing and that drug companies are allowed to write off their advertising expenses as tax breaks.
A man yelled, “Oh no!” The woman to his left: “Stop it!”
McCaskill trumpeted a committee report she issued, which demonstrated that in recent years the 20 most-prescribed Medicare drugs have risen in price by nearly 10 times the rate of inflation. The crowd grumbled.
She talked about gag clauses (to sighs) and her bill to prohibit them (to more claps).
Having established herself as the drug pricing candidate, McCaskill is selling voters not just on policy but on the fear she has instilled in the pharmaceutical industry.
So convinced is McCaskill of her status as the industry’s sworn enemy that in speeches across the state and even in campaign ads, she has taken to accusing the pharmaceutical industry of funding personal attacks against her. She tells voters to envision the drug industry’s proverbial “dartboard,” and says she is at the center.
Speaking to reporters following her on the trail in Columbia, McCaskill provided no evidence to support her claim. Instead, she rattled off reasons the drug industry should fear her: the list of legislation she’s passed and oversight efforts she has launched.
Most of the so-called “dark money” ads in Missouri — the ones paid for by groups that are not required to disclose their funders — have focused on dubious claims regarding the personal wealth of McCaskill’s husband and her vote against the Republican tax reform bill this year, among other topics. There aren’t any major ad campaigns attacking McCaskill for her stance on a specific health care issue.
PhRMA, the leading trade group for pharmaceutical manufacturers, declined to comment, but would not deny that the group was behind the attack ads.
In Washington, where she often likens pharmaceutical industry campaign contributions to a corrupting “fairy dust,” even McCaskill is not entirely clean.
She has accepted a handful of campaign contributions in the past two years from drug manufacturer PACs, according to a STAT review of campaign finance disclosures: $2,500 from Pfizer (PFE), $4,500 from Bayer (BAYRY) — not zero, but still a notably low amount for a competitive Senate candidate.
The St. Louis-based drug manufacturer Mallinckrodt (MNK) has also donated to McCaskill’s campaigns in the past, but has not done so this cycle. The company was among the targets of a McCaskill investigation into the opioid crisis in 2017, as her committee sought to determine whether several manufacturers had maintained appropriate safeguards against their drugs entering the black market.
When it comes to ties to the pharmaceutical supply chain, McCaskill’s biggest benefactor is not manufacturers or distributors but pharmacy benefit managers, the bulk-purchasing middlemen who have been the target of harsh rhetoric from President Trump and members of Congress from both parties.
Express Scripts, the nation’s largest PBM, has written McCaskill numerous four-figure checks over the past 15 years. McCaskill has taken $90,287 from the company and its employees so far in the 2018 cycle, and a combined $71,058 in 2012 when she last ran for Senate, according to the Center for Responsive Politics.
Perhaps she is beholden to geography: Express Scripts’ sprawling corporate headquarters straddle I-70 in the outskirts of St. Louis.
(Another frequent contributor: the health insurance industry. Corporate PACs aligned with the country’s five largest health insurance companies have combined to give McCaskill $25,5000 in the past two years.)
“To make it seem like Claire is this purist who hasn’t taken corporate money wouldn’t be an accurate depiction,” said another lobbyist who works on drug supply chain issues and also requested anonymity to speak.
Despite the donations from PBMs, McCaskill has conducted some oversight of the PBM industry, such as an investigation with Sen. Rob Portman (R-Ohio) that included an extensive request for internal Express Scripts documents.
She was also a lead co-sponsor on legislation Trump signed into law earlier this month that cracked down on the PBM practice of requiring “gag clauses” that prevented pharmacists from telling patients whether they could buy a drug more cheaply over the counter. The bill was so noncontroversial, however, that it even had the public support of the PBM lobby.
McCaskill has not yet publicly supported one of the strongest bills that takes aim at PBMs: legislation to force increased transparency in the industry, from Sen. Ron Wyden (Ore.), a fellow drug pricing hawk and the top Democrat on the Senate Finance Committee, which holds most jurisdiction over pharmaceutical companies.
In truth, few members of Congress have aggressively pursued the PBM industry until this year, which has seen Trump make angry speeches about “middlemen” and the PBM trade group’s top lobbyist step aside after 15 years. Even the Trump administration has waffled on whether to rein in PBMs — or to give them more power over the drug makers they negotiate with.
McCaskill, however, appears more prone to take sides. In a rare public spat between a PBM and drug manufacturer, for example, her committee has sided with the PBM.
Kaleo, a company that makes a version of the opioid antidote naloxone, has taken flack in recent years for hiking the list price for two of its naloxone auto-injectors to $4,500 — a move it argues increased patient access while preserving free access to nearly all who seek the drug. The company has blamed the price hike on Express Scripts.
Though the two companies remain locked in a court battle, the committee McCaskill stands to inherit asked only Spencer Williamson, the Kaleo CEO, to testify before Congress.
In St. Charles, McCaskill said she hasn’t excluded PBMs as she’s probed high drug costs, even if much of her recent oversight work has focused on manufacturers.
“There is not any part of the system that I haven’t taken a look at,” she said during a brief interview. “I think that’s what’s called going after the issue and not just going after your political bottom line.”
Over the weekend, McCaskill took a pause from the drug-pricing talk, using the events surrounding her alma mater’s homecoming to swipe at her opponent’s Ivy League credentials.
“Josh Hawley is a Yale-trained lawyer,” McCaskill, who attended high school in Columbia and holds two degrees from the University of Missouri, would tell everyone in earshot. “I’m a Mizzou-trained lawyer, but I can keep up.”
McCaskill brandishes that lawyerly background when attacking Hawley, Missouri’s attorney general, for his position on pre-existing conditions.
Step by step, McCaskill walks her crowds through the legal principle of severability — explaining that if Hawley wanted the lawsuit to leave pre-existing conditions alone, he and the Republican attorneys general making the legal case could have done so.
Hawley, whose older son has a pre-existing health condition, has pushed back forcefully, writing in an op-ed that Democrats have “used the stories of people with pre-existing conditions, like my son, as pawns in their effort to protect President Obama’s legacy.”
To the delight of crowds at campaign rallies, McCaskill is also making sure her prosecutorial approach to drug maker oversight is on full display.
Part of her closing argument in St. Charles: an investigation into Insys, a manufacturer of a powerful prescription opioid. Per McCaskill’s 2017 investigation, the company operated by the slogan: “Start them high and hope they don’t die.”
The crowd was silent as McCaskill described the company’s effort to manipulate pharmacies to ensure access to the drug at all costs — in at least one case, salespeople posed as doctor’s offices, which resulted in a young woman’s overdose and death.
As McCaskill paused for effect, a man in the back shouted: “They should have gone to jail.”
McCaskill told him what he’d hoped to hear: In October 2017, federal agents arrested the Insys CEO, John Kapoor.
It was the loudest applause McCaskill had received all morning.