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Health Care Reform:

Health Insurance & Affordable Care Act

Castellani: Health Law’s Cost-Sharing Could Limit Patient Access To Prescription Drugs


In an interview, Castellani said that higher cost-sharing requirements for the law’s silver and bronze plans are “a concern for us from the patient standpoint, obviously, because you’re disincentivizing patients, particularly patients with chronic diseases, to continue to manage their chronic disease in exchange for what was a political imperative, which was a low premium, as low as possible,” he said. “Yet their out-of-pocket expenses are potentially so high that we have to be concerned about whether or not people will be able to afford to continue to get their medicines.”

The average cost-sharing “tiers” for prescriptions on the bronze and silver plans are also higher than employer-sponsored plans, according to the report. For example, average co-pays for employer sponsored insurance for specialty drugs are $80, compared with $159 for silver plans and $157 for bronze, it notes.

Some of those costs may be mitigated by the law’s cost-sharing subsidies for silver plan enrollees whose incomes are up to 250 percent of poverty (about $28,725 for an individual, higher for families), with the assistance greatest for those at the lower end of the income scale. Those subsidies reduce the deductibles and other out-of-pocket costs people are required to pay. Insurers have some flexibility on how that cost-sharing is reduced but the plans must meet specific actuarial values. The cost-sharing subsidies do not apply to other plans sold on the exchanges.

Insurers can exclude some medications, like generics, which account for 86 percent of all drugs dispensed, from a deductible but still require other cost sharing. The more expensive the drug, however, the more the consumer usually pays out of pocket.

Castellani said PhRMA has brought its concerns to the health insurance industry, to the Department of Health and Human Services and to patient groups, among others.

Clare Krusing, a spokeswoman for America’s Health Insurance Plans, a trade group representing insurers, said the problem is that drug prices are too high.

“Research shows that drug prices continue to soar and are one of the leading drivers of health care cost increases. Any discussion of prescription drug coverage must also include a focus on the direct link between rising prescription drug prices and consumer cost-sharing,” she said in a statement. “Rising prices for prescription drugs put a financial burden on patients by forcing them to pay for these cost increases through higher premiums or increased out-of-pocket costs.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Wed, May 07 2014

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