This Biden measure will hurt mental health care in rural NC | Opinion

North Carolina faces a rural mental health crisis. We’re seeing a rising tide of conditions like loneliness, depression and suicide, combined with a shortage of the professionals and services we need.

Yet even as community organizations and government agencies take steps to address the situation, a single provision of a new federal law is poised to make it much worse.

The Inflation Reduction Act, President Biden’s signature legislative achievement, contains a number of rules that will affect the cost and availability of prescription medicine. Some of its components will improve access. But unless one provision is revised, the law could make it even harder for rural residents to get mental-health treatment.

In general, people living in rural areas are more likely to experience depression and suicide compared to urban populations, but they have less access to mental health services.

In North Carolina, rural residents have higher rates of poverty, unemployment and alcohol and drug abuse than their city-dwelling counterparts. All these factors can contribute to mental health issues. Meanwhile, nearly a third of N.C. counties — all of them rural — lack a single practicing psychologist. According to the Kaiser Family Foundation, only 13% of mental health needs are currently being met across our state, well below the national average of about 28%.

One way to ameliorate this situation would be by making sure that patients have access to the best medication to treat their mental illness. But unfortunately, the IRA does the reverse.

The most common drugs used to treat depression, anxiety, schizophrenia and other mental disorders are “selective serotonin reuptake inhibitors,” or SSRIs — such as Prozac, Zoloft and Lexapro. These are classed as “small molecule drugs” due to their low molecular weight.

Due to their small size, these medicines are able to cross the blood-brain barrier, making them effective at treating mental health conditions. Small-molecule drugs are also accessible given they often come in pill or tablet form. This makes them convenient to pick up from a local pharmacy, even for patients who have to travel far to see a doctor.

The problem is that the IRA discriminates against this entire class of drugs.

For the first time, the bill makes it possible for Medicare to negotiate with drug companies to set the price of prescription medicines. Large-molecule “biologic” drugs — which tend to cost patients more out-of-pocket and often have to be administered by injection in a clinic — are exempt from price negotiations for the first 13 years after approval. But small-molecule drugs are exempt for just nine. This four-year gap may sound small, but the impact could be profound.

It costs more than $2 billion and can take more than 10 years to develop a single drug all the way from laboratory bench to pharmacy shelf. Drug companies are able to invest this much time and money because they know they’ll be able to earn a return on their investment once a successful medicine hits the market. A shorter exemption period means less time to earn a return — and considerably more risk that the company might never do so.

The IRA’s “small-molecule penalty” is already having an impact on drug development. It has prompted both pharmaceutical companies and investors to shift funds away from small-molecule research in favor of the development of biologics, given their more limited exposure to IRA price setting. Ultimately, this means we’ll see much less development of the very medicines that people with mental illness in rural areas most need.

There’s a way to fix this before we start to see these catastrophic consequences. Lawmakers should consider amending the IRA to provide a 13-year exemption period for all drugs, not just biologics. This will help rural residents in North Carolina — and throughout the United States — achieve better mental health over the long term.

Jimmy Gentry is president of the North Carolina State Grange, which advocates for rural North Carolina. He lives in Statesville.