Pharmacy Required to Split Cost of Patient's Insulin

The Issue

A patient in a mid-Atlantic state filed a lawsuit on his own, seeking to have his physician and 2 chain pharmacies split the cost of his insulin and rooting his argument in the Affordable Care Act (ACA). This framed the issue of whether that federal statute gives individuals the authority to maintain in federal court a private action for enforcement in this manner.

The Facts

The plaintiff in this case acted without an attorney, which the law refers to as being a pro se litigant, meaning “proceeding for one’s self.” (In fact, the court pointed out early in the opinion that this plaintiff was a “frequent, albeit frequently unsuccessful, pro se litigant.”) He also sought permission to proceed in forma pauperis; that is, he requested that the filing fees ordinarily paid to initiate a lawsuit be waived.

The plaintiff, a patient with diabetes, filed the suit to request that the court order the pharmacies and physician to split the cost of his insulin until he could find a way to pay for the medication. The lawsuit was filed in a US District Court because the claim allegedly arose under a federal statute.

The matter was referred to a US magistrate judge for a recommendation on motions for dismissal made by the defendant pharmacy chain. A magistrate judge is a US district court official who handles matters—usually minor or administrative issues—assigned by federal statute or delegated by the judges of the district court with which he or she is affiliated. Unlike a district court judge, a, magistrate judge is not appointed for life or nominated by the president and confirmed by the US Senate.

The first matter taken up during review of a pro se complaint is whether the filing fails to state a claim upon which relief may be granted, so that was the focus when the magistrate judge took up the pharmacies’ motion to dismiss.

The Ruling

The magistrate judge ruled that the complaint failed to state that claim and forwarded a recommendation to dismiss the complaint to the district court judge with whom he was working. Because the plaintiff was proceeding pro se and in forma pauperis, the magistrate judge recommended that the suit be dismissed without prejudice, meaning that it could be revised and brought back. However, any modifications had to be submitted within just 20 days. The supervising judge concurred and entered the order.

The Court’s Reasoning

The magistrate judge pointed out that the analysis starts with identifying legal filings to initiate the lawsuit that, because they only conclusions, are not entitled to the assumption of truth. A complaint must “recite factual allegations sufficient to raise the party’s claimed right to relief beyond the level of mere speculation.” The judge used a 2-pronged approach: first, separating the factual and legal elements, accepting all well-pleaded facts as true but disregarding any legal conclusions; and second, determining whether the facts alleged sufficiently show a plausible claim for relief.

The judge reviewed the legal filings and concluded that “the lawsuit rests on a legally flawed premise: namely, the notion that the Affordable Care Act creates some implied private right of action which empowers federal courts to order private parties to wholly subsidize and fund medication costs for an individual.”

A review of the ACA statute focused on 2 questions: Did Congress intend to create a personal right, and did Congress intend to create a private remedy? The answer to each was no. The only precedent that could be located based on prior cases involving interpretation of the ACA was that the statute would be relevant to the plaintiff’s claim only if he could show that he was subjected to discrimination in gaining access to health services based on age, race, gender, or disability. The plaintiff alleged none of those.

Dr. Fink is a professor of pharmacy law and policy and the Kentucky Pharmacists Association Endowed Professor of Leadership at the University of Kentucky College of Pharmacy, Lexington.