How Washington Can Save Patients Money on Prescription Drugs Right Now

How Washington Can Save Patients Money on Prescription Drugs Right Now
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Washington policymakers are making prescription drug reform a top priority. This is commendable, considering that roughly three in 10 Americans admit they haven't taken their drugs as prescribed because of high, out-of-pocket pharmacy costs.  

There's no question that our healthcare system is broken. Where there is disagreement is in how to fix it. Current proposals being considered by the Congress do little to address the out-of-pocket spending requirements and insurance company access restrictions that impose the biggest burdens on patients. Failing to address these issues would be a huge missed opportunity.

That isn't just an economic or moral problem -- it's a major threat to public health. For the individuals I work with, many of whom live with HIV/AIDS or hepatitis, failure to take their drugs puts their lives and the lives of others at risk -- since untreated HIV or hepatitis B or C can spread to others. People who suffer from common ailments -- like diabetes, high blood pressure, and heart disease -- can spiral out of control when they don't take their medicines.

These affordability challenges are largely the fault of private insurers, which are shifting more and more costs onto patients. For privately insured Americans living with HIV, for instance, prescription-drug cost-sharing increased by 50 percent between 2015 and 2019, according to consulting firm IQVIA.

There are several policies that the Biden administration and Congress can advance right away that would solve the challenges facing patients.

The first is to fully enforce the anti-discrimination provisions included in the Affordable Care Act. This component of the law prohibits payers from discriminating against patients based on disability or health conditions. Yet that's precisely what insurers do when, for example, they place all medicines for certain diseases on their highest cost-sharing formulary tier or when they force patients to try cheaper, less-effective medicines before granting approval for more expensive alternatives.

Federal policymakers should also institute a cap on the amount that patients can pay out-of-pocket for a given prescription in a single month. California, Maryland, Louisiana, and President Biden's home state of Delaware already do this.  It's one of the most direct ways to keep pharmacy costs down for those struggling to pay for their drugs.

Requiring every insurer to offer policies which don't count prescription drug costs towards a health plan's deductible is another reform that would help.  That'd help many patients who need expensive medications stay on their prescription regimens in the first months of the year, when insurance plans reset and patients face hefty out-of-pocket fees before insurance coverage kicks in. President Biden should be applauded for addressing this matter in his recent address to the Congress when he said, "Let's lower deductibles for working families on the Affordable Care Act."

Similarly, federal officials could require insurers to count copay assistance coupons towards patients' annual out-of-pocket spending maximums. Currently, many insurers aren't counting those coupons and effectively double billing, charging once via the coupon and then again via a copay at the pharmacy counter that the patient has to pay.

Finally, it's time policymakers put a stop to insurers' behavior regarding manufacturer rebates. Each year, drug companies provide more than $150 billion worth of rebates and discounts to insurance companies and pharmacy benefit managers (PBMs).  Instead of using these price-reductions to lighten the out-of-pocket burden on patients, insurers pocket most of these rebates.

Requiring coverage providers and PBMs to pass on some level of manufacturer price reductions directly to patients would help bring down out-of-pocket drug costs considerably, while ending one of the most unfair, underhanded tactics employed anywhere in our healthcare system.

These concrete policy changes would save Americans money on prescription drugs right now and make it easier for the nation's most vulnerable patients to stay healthy. That's why my organization, along with over 120 other patient advocacy groups, recently fleshed out these recommendations in a letter to Health and Human Services Secretary Xavier Becerra.

Congress and the Biden administration have a once-in-a-generation chance to make the healthcare system work better for patients. Let's hope they actually address the barriers that insurers put up that prevent folks from getting the medicines they need.

Carl Schmid is executive director of the HIV+Hepatitis Policy Institute, which promotes quality and affordable health care for people living with or at risk of HIV, hepatitis or other serious and chronic health conditions.

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