This article originally appeared on STAT
For years, insurers dropped sick people from their plans or denied coverage due to preexisting conditions like cancer, keeping them from the care and medicines they needed. The Affordable Care Act (ACA) was supposed to make it unlawful for insurers to refuse coverage to such individuals or charge them more for health insurance. But it is still happening.
No longer able to keep patients off their plans outright, insurers have resorted to other ways to discriminate and avoid paying for necessary treatments. Specifically, they have imposed specialty tiers and high copays or coinsurance for prescription drugs that effectively force sick people to delay needed care or to find a different health plan. So much for the end of preexisting conditions.
Covering fewer sick patients translates to bigger profits for Big Insurance, but less healthcare for those who need it most.
A recent study from Harvard examined insurers’ use of these tactics. They found 12 plans on the ACA exchanges that discriminated against people with HIV by making them pay $3,000 more a year than those in other plans. This work highlights that such action “has the discriminatory effect of discouraging individuals in need of specific medications from enrolling in these plans or of shifting the burden of the cost back to these enrollees”.
Harvard’s Center for Health Law and Policy Innovation recently filed a landmark discrimination complaint with the Federal Office for Civil Rights against seven major insurers. The complaint noted that “Unaffordable cost sharing is just as much a barrier to care as outright refusal to cover medications … Left unchecked, these practices will drive individuals out of the health insurance market, leaving them once again without meaningful access to care.”
States from New York to Florida have attempted to take action against insurance companies found to be engaging in the practices. The federal government should also take a stand – both under the law and in the spirit of the ACA – to stop these unfair and discriminatory practices.
In June, the Centers for Medicare and Medicaid Services (CMS) announced $22m in funding to state insurance departments earmarked toward “implementing … consumer protections including: essential health benefits, preventive services, parity in mental health and substance use disorder benefits, appeals processes, and bringing down the cost of health care coverage (also known as medical loss ratio provision)”.
By any standard, “essential health benefits” must include access to needed medications. Yet the CMS language does not explicitly make this point. That should be corrected, as the federal government must make clear that discrimination against patient access to medicines will not be tolerated.
As a biotechnology CEO and chair of Bio, the world’s largest association of biotech companies, I spend most of my time working to develop innovative medications and to ensure that patients have access to them.
For years, the insurance industry and its allies have deflected attention from their responsibilities by pointing fingers at innovative biopharmaceutical companies, claiming that prescription drugs are the major driver of insurance premium increases. As study after study has shown, that’s simply false. For example, a recent independent study from Avalere showed that just 14% of 2017 premiums will be driven by pharmaceutical prices versus about 73% for inpatient, outpatient and professional services. And keep in mind that innovative prescription drugs actually save the healthcare system money over time through reduced surgeries and hospital stays and curbing of doctor visits.
The federal government needs to step up and take action against insurance companies that – while technically barred from dropping people with preexisting conditions – are nevertheless discriminating against them to achieve the same ends.
