Exchange plans are failing America’s most vulnerable

The Affordable Care has helped millions of Americans access health insurance. But the quality of coverage insurers are currently offering is worrisome. Even with federal subsidies, many available plans make paying for medications to treat cancer, HIV/AIDS, autoimmune diseases, and other serious conditions totally unaffordable. If the Affordable Care Act doesn’t help the most vulnerable pay for treatment, who is it helping?

A report by the research group Milliman found that 46 percent of all enrollees with a Silver plan -- the most popular level of coverage -- have a single, combined deductible for medical and pharmacy benefits. As a result, it’s not uncommon for patients to pay more than $2,000 out of pocket before they get any drug coverage.

Compounding this problem is the high cost-sharing in most plans. Typically, insurance plans have four or five cost-sharing tiers. The lowest tier might have a co-pay of $15 for prescription drugs, while the highest tier might require patients to pay 40 percent or more of the actual cost of the medication. Such cost-sharing can run patients hundreds of dollars per month or more.

A new report by Avalere health analyzed cost-sharing in Affordable Care Act plans for 19 classes of prescription drugs used to treat specific illnesses. The results are troubling.

A shocking number of treatments are in the top cost-sharing tier. In seven of the classes, one in five Silver plans require coinsurance of 40 percent for all covered medications.

Additionally, more than 60 percent of Silver plans put all medicines for treating autoimmune diseases such as multiple sclerosis, arthritis and Crohn’s disease in the top tier.

Adding to this difficulty, many patients have reported that when signing up for insurance, they can’t determine what their co-pays will be. Few insurers are offering to help patients determine which level of coverage is best for their individual therapies.

The bottom line is that many Americans with serious health problems who signed up under the Affordable Care Act are finding that they have to pay thousands of dollars out of pocket just to get treatment.

Patients with these conditions have to make a decision about what they can afford. And that decision is often to save money by skipping medications.

The cost associated with non-adherence to prescription drug regimens is particularly problematic with autoimmune diseases. Autoimmune diseases are responsible for $100 billion in medical costs annually, and much of that is because patients have trouble staying on top of their treatments and end up in hospitals. By making autoimmune drugs unaffordable, these plans could make other health care costs explode. What’s more, 75 percent of those suffering from autoimmune diseases are women. Aside from harming those with chronic health problems, the formularies these plans offer are discriminatory.

Making sure patients have access to drugs saves money. According to the Journal of the American Medical Association, the expansion of drug access through Medicare Part D saves $12 billion annually. That’s because medications enable patients to manage chronic conditions and avoid expensive trips to hospitals.

The lack of transparency in the marketplaces has also proven to be a problem. Many patients with chronic conditions might have been better-off selecting a Gold plan instead of a Silver or Bronze plan. It’s difficult to compare the bottom-line costs of plans offering higher monthly premiums but better drug coverage and plans with lower premiums but higher deductibles and co-pays.

The top priority of the Affordable Care Act is in its name: affordability. Instead, it’s putting basic health care out of reach for many of the sickest Americans. Insurance under the president’s health care law must pay for essential prescription drug treatments.

Virginia Ladd is the president and executive director of the American Autoimmune Related Diseases Association.



Published: Oct. 23, 2014 - Volume 13 - Issue 28