Cathy Kerns expected to spend her retirement savings as her friends do: on cruises or other "golden years" indulgences. Instead, she's spending her money on pills — 14 medications she takes daily to control multiple sclerosis, lupus and other ailments.
"Many times you find yourself struggling to find the money to try to stay medicated," said Kerns, 66, a retired advertising executive who lives in Orlando, Fla.
That concern about the cost of prescription drugs has emerged as a big issue in the presidential campaign, prompting candidates in both parties to sharpen their rhetoric against pharmaceutical companies and put curbing drug prices at the center of their healthcare plans.
The message is particularly resonant here in Florida, which holds its primary Tuesday and where people over 60 make up more than a third of registered voters.
At the Democratic debate in Miami on Wednesday, Sen. Bernie Sanders repeatedly castigated drug companies for "ripping off" the American public.
Hillary Clinton has vowed to rein in drug prices and is running an ad in Florida specifically focusing on the "predatory" pricing of one embattled pharmaceutical company, Valeant.
Drug manufacturers also have become a punching bag on the right. Sen. Marco Rubio has called the industry's practices "pure profiteering," and Donald Trump wants to let Medicare negotiate drug prices, a break from Republican orthodoxy.
Pharmaceutical companies "have a fantastic lobby — they take care of all the senators, the congressmen," Trump said in Thursday's GOP debate. He promised he would be a hard-nosed negotiator because he was not dependent on industry money.
The issue also will appear on California's ballot this fall, in the form of an initiative that would restrict how much the state could pay for prescription drugs. Pharmaceutical companies already have socked away nearly $40 million to oppose the measure.
The politicization of drug prices come as costs have surged after years of relatively small increases. In 2014, spending on retail prescriptions rose more than 12%, compared with a 2% growth rate the year before. Most of the spending was driven by new specialty drugs, which treat diseases that affect relatively few people, such as hemophilia or end-stage cancer.
Robert Zirkelbach, a spokesman for the Pharmaceutical Research and Manufacturers of America, the industry's main trade group, said the jump was an anomaly and not an overall trend.
But Joel Hay, a health economist at USC, said he expects specialty drug prices to keep climbing.
"The industry has figured out that this is where the money is," Hay said.
Across-the-board increases on existing drugs also have driven up costs, said John Rother, president of the National Coalition on Health Care, an advocacy group. He also pointed to "one-off situations," like the decision by Martin Shkreli, the former CEO of Turing Pharmaceuticals, to increase by 5,000% the price of a drug that combats rare infections.
Clinton in particular has relished jabbing at Shkreli, calling him, at one point, "the worst bad date you can imagine."
Drug companies note that much of the debate centers on list prices, which can be staggering five- or six-figure amounts. Few insured consumers pay those amounts; instead, their co-pays typically are a fraction of a drug's sticker price.
Still, as drug prices have climbed, so have patients' out-of-pocket costs. Kerns, for example, said her 20% co-pay for a multiple sclerosis treatment was manageable when the drug cost $900 a month, but over time, the monthly price rose to $10,000.
"It just became crazy," she said.
The shift toward high-deductible insurance plans also leads to steeper out-of-pocket costs, said Zirkelbach, who notes that many manufacturers offer rebates or other financial assistance to ease patients' burdens.
Drug costs have been thrust further into the spotlight by a sophisticated advocacy campaign, backed by health insurers, physicians, labor unions and other interest groups that want to force drug companies to cut prices.
The National Coalition on Health Care's effort to raise the issue's profile — including sending volunteers into early primary states to attend candidate events and ask questions about drug prices — has yielded fruit in the 2016 campaign, evident in frequent mentions of pharmaceutical costs on the campaign trail.
Overall, however, candidates' proposals come up short, policy experts say.
Sanders and Clinton, like Trump, support letting Medicare bargain with manufacturers for lower drug prices. The federal government has been barred from such direct negotiations since 2003. The nonpartisan Congressional Budget Office, however, said such savings would be "negligible" unless the government limited which medications would be covered, a politically controversial idea.
Other proposals meant to slash prices — such as importing treatments from abroad or requiring companies to disclose their spending on research and marketing — may have the effect of chilling development of new medicines, Hay said.
"If you restrict prices on drugs, manufacturers will stop inventing new drugs," he said.
To move beyond its defensive crouch, the pharmaceutical industry has made proposals of its own, such as streamlining the federal approval process for new drugs. Clinton and Texas Sen. Ted Cruz both have called for swifter action by the Food and Drug Administration on that front.
"We have a responsibility as an industry to be coming to the table with solutions," Zirkelbach said.
Some voters believe that what the industry is really bringing to the table is money. Brad Esposito, an independent pharmacy owner in Tampa, said he wasn't sure which contender would be best suited to take on what he sees as pharmaceutical companies' "corruption."
"I don't know who would be better," said Esposito, a Republican, "this is a huge multibillion industry, and I'm sure half of these companies are financing their campaigns."
People who work in the pharmaceutical and health products industry and PACs linked to the industry have given more than $1.2 million to presidential candidates so far, according to the nonpartisan Center for Responsive Politics; the top recipient, Hillary Clinton, has received more than $400,000.
Kerns, a Democrat, is similarly unsure any candidate has the solution.
Meanwhile, she continues to feel the squeeze of her daily drug regimen: In the morning, 13 pills, followed by eight pills at noon and 19 at bedtime.
"Trust me, I bless the pharmaceutical industry for at least coming up with medications that were able to modify the diseases I live with," Kerns said.
But, she added, "We are being held — our feet to the flames — because we have no other options. I either quit taking a drug, or I may die or get progressively worse. Or I just suffer by using all of my funds."