More Affordable Care Act plans are raising the out-of-pocket costs of medicines used to treat chronic diseases such as cancer and HIV for 2015 . According to a recent analysis by Avalere Health, the percentage of silver plans—the most popular plans in the health care marketplace—that are charging a coinsurance of 30 percent or more for these therapies has increased from 27 percent in 2014 to 41 percent in 2015.
Insurance companies keep their costs down by asking patients to pay for part of their care, usually either via coinsurance, whereby patients pay a certain percentage of their medical expenses, or copays, whereby patients pay a fixed amount for a given service. The problem is that these costs are generally impossible to estimate during the shopping process. “Medication costs are negotiated by health insurers,” Michael Ruppal, executive director of the AIDS Institute, said. “So shoppers don’t know what their costs will be until their claims are processed. How do you project costs with open-ended expenses like that?”
We’re most fearful that the good plans are going to start mirroring the bad ones, because they’ve been allowed to get away with it
Beyond the cost mystery lie possibly intentional discriminatory practices that insurance companies seem to be using more and more. “Discrimination is mentioned in the statute but not well-defined under the Affordable Care Act,” Dan Mendelson, CEO of Avalere Health, said. “It will be necessary for the Center for Medicare and Medicaid Services to carefully consider what constitutes discrimination, in consultation with patients, health plans and other stakeholders.”
Last year, the AIDS Institute and the National Health Law Program (NHeLP), an organization dedicated to protecting the health rights of low income and underserved individuals, filed a complaint with the Department of Health and Human Services, claiming that four health insurers in Florida were violating the anti-discrimination provision of the Affordable Care Act by placing all HIV medications in tiers that required a high coinsurance.
Following the filed complaint, researchers at Harvard University conducted their own analysis of HIV medicine coverage in exchange plans across 12 states. The results, published in The New England Journal of Medicine, showed that 25 percent of the examined plans used discriminatory tiering practices for a commonly prescribed class of HIV medications .
As a result of the AIDS Institute’s complaint, one of the four insurers agreed to recategorize certain HIV medicines into lower-cost tiers. But Ruppal doesn’t classify the concession as a win. “It shouldn’t have happened in the first place,” he said. Now the AIDS Institute is looking to join forces with other patient advocacy organizations to conduct similar analyses for other diseases and states. “Cancer, diabetes and other diseases are also being singled out by health care companies,” Ruppal said. “That unfairly shifts the burden onto the plans that followed the spirit of the law.”
The organization will also continue to advocate ongoing reviews at the state and federal level to protect patients from such discriminatory practices. “We’re most fearful that the good plans are going to start mirroring the bad ones, because they’ve been allowed to get away with it,” Ruppal said. “And then we risk losing the program altogether for the patients who need it most.”