Burden on Patients: Looking Ahead

Without access to essential health care treatments and services, having health insurance coverage is pointless.

Allyson Funk
Allyson FunkJuly 17, 2014

Without access to essential health care treatments and services, having health insurance coverage is pointless. Being covered should equate to high-quality, affordable health care, but this is not the case for many individuals in the Affordable Care Act (ACA) health insurance exchanges. According to an analysis by Avalere Health, patients in the exchanges that suffer from chronic conditions may have face hurdles in accessing needed treatments.

Over the past few weeks we have examined this issue through our Burden on Patients blog series. Specifically focusing on individuals with rheumatoid arthritis, HIV/AIDS, mental health disorders, multiple sclerosis, asthma, diabetes and cancer, the evidence clearly shows that patients with exchange coverage may struggle to get the treatments they need as a result of high out-of-pocket costs and restrictions in coverage of prescription medicines. Under the current benefit design, patients with chronic conditions are getting hit twice. Not only do many exchange plans have a single deductible for both medical and pharmacy spending – which means patients may pay $2,000 or more out-of-pocket before any of their medicines are covered – but many exchange plans also require patients to pay an additional 30 to 40 percent out-of-pocket for needed treatments.

So how can we address this issue?

Federal and state oversight could have a tremendous impact on helping the ACA live up to expectations and provide patients with access to the high-quality, affordable health care they deserve. Thorough reviews of exchange plan formularies – including tier placement and utilization management – would help prevent problematic benefit designs, including those that place all medicines in a class on the highest cost-sharing tier.

For patients, access to the treatments and services they need to live longer, healthier lives is essential, and as long as health insurance exchange plans fail to make needed medicines accessible to patients, health care reform is not complete. As Epilepsy Foundation Vice President Angela Ostrom said, “People living with epilepsy who have had trouble gaining access to health insurance in the past due to pre-existing conditions had hoped to gain meaningful access to medications and quality care through marketplace plans. If they cannot afford the medications their providers think are best for them, we have not delivered on the promise of the Affordable Care Act.”

The biopharmaceutical industry is committed to working with the Administration, insurance companies and other stakeholders to help ensure the ACA delivers on its promise to patients. We encourage you to share your thoughts with us via Facebook or Twitter, and check out all of the Burden on Patients series.

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