Dirigo or die Maine is spearheading the fight against Big Pharma — and winning BY ALEX IRVINE

Last Friday, a group of state legislators, mostly from New England, met in an Embassy Row hotel in Washington, DC. The agenda, compressed into a single six-hour flurry, included a new nonprofit pharmaceutical benefit management (PBM) company; the status of Vermont’s lawsuit over reimportation of prescription drugs; a proposal for the use of eminent domain to ensure better access to generic drugs; and a host of other topics related to that most vexed and complicated of contemporary issues, prescription drugs.

The group is called the National Legislative Association on Prescription Drug Pricing, or NLARx. It was founded as a regional association in 1999, when both Maine and Vermont were trying to pass versions of what in Maine is known as MaineRx, and among its founders were Maine state legislators Chellie Pingree (now head of Common Cause) and Steven Rowe (now Attorney General); Vermont state senators Peter Shumlin and Cheryl Rivers; and other representatives from the New England States. "They got together," says current NLARx Executive Director Sharon Treat (formerly Maine Senate President), "and said, ‘we’re being picked off one by one by the pharmaceutical industry. Wouldn’t it make sense if we banded together and jointly did stuff across the region?’ "

Since then, the association has grown to include members from Pennsylvania, the District of Columbia, and Hawaii, with increasing interest from other states where legislators look at Maine’s recent successful defense of MaineRx as a possible signal that the states can begin to take their drug-pricing destiny into their own hands.

This has been part of NLARx’s mission from the beginning, says Treat from the organization’s Hallowell headquarters, "especially recognizing that little if anything was going to happen nationally" as long as Big Pharma-friendly Republicans were calling the shots in Congress and the White House.

Maine legislators have taken the lead on the pharmaceutical front from the beginning, says Treat. "They helped found this organization, the leadership has appointed a full complement of legislators to the organization, Senator [Art] Mayo is going to be the new treasurer. Maine and Vermont have always taken the lead on this, and it’s clear they’re going to continue to do that."

NLARx has positioned itself to become more of a national player with the recent appointment of Portland state rep John Brautigam to its board of directors. Brautigam was part of the Attorney General’s team that successfully argued MaineRx’s case before the Supreme Court two years ago. "Obviously that was a rare opportunity for anybody," he says, "a rare thing for an attorney to get to sit at that table, and it was quite a great moment. All the better that we ended up prevailing."

The statute that created MaineRx provided for the hiring of an assistant Attorney General in the event that Big Pharma tried to gum up the works, and Brautigam was the state’s choice. "I had a background in constitutional litigation" from his work at the Maine Citizens Leadership Fund, he says, "and a lot of the issues were constitutional in nature." While waiting for the MaineRx case to wend its way upward to the Supreme Court, Brautigam also got involved in another standardbearing legislative drive that originated here in Maine.

"I developed into one of the Attorney General’s key people on prescription-drug pricing matters," he recalls. "AG Rowe was really at the forefront, and continues to be at the forefront, on prescription-drug price issues. That put me right in the mix of some national discussions and some litigation with the other attorneys general," including antitrust cases involving Big Pharma’s efforts to limit access to cheaper generic drugs.

But Brautigam’s current target is the pharmaceutical benefit-management (PBM) industry, whose "dealings and negotiations with drug manufacturers have not been subject to scrutiny by any regulatory authorities, or by the health plans themselves," he says, with the result that PBMs contribute to the runaway cost increases seen in the health-care industry in recent years (in no small part due to a propensity for fraud and kickbacks).

Brautigam was co-chair of a national attorneys-general task force that investigated the industry and began to take behind-the-scenes action to prevent its worst abuses. "This was something that we did quietly for a couple of years, and then it was last April that the task force went public and announced a settlement with Medco Health Solutions, one of the largest PBMs in the country, to protect consumer interests and bring some transparency to that industry," he says. In addition, the Maine legislature — led by the since-term-limited Treat — passed rules requiring transparency in PBM operations; that legislation, and a similar decree from the District of Columbia, are currently under injunction while the AGs and the pharmaceutical industry hash things out in court.

"It was a lot of fun to be right in the middle of that," Brautigam says, "and we were actually the first state to begin pushing that investigation," which is ongoing and now includes as many as 30 attorneys general.