Opinion: Co-pay accumulators hurt patients' ability to afford innovative new treatments. That needs to stop.
John Lombardi is a state representative serving House District 8 in Providence.
The past few years have been a struggle for our community, but I’ve been amazed by the resilience of Rhode Islanders. As a state representative, I’ve had the privilege of helping constituents weather the pandemic by passing legislation that invests in our public health system. Unfortunately, COVID exacerbated many existing problems, and with inflation still at a 40-year high, we must look at ways to ease the financial burden some of our most vulnerable citizens — those impacted by chronic disease — are now facing.
Over the past 20 years, modern medicine has made incredible advancements in treating life-threatening illnesses, including cancer, ALS, hemophilia, cystic fibrosis and lupus. Just this past fall the U.S. Food and Drug Administration approved a drug for Type 1 diabetics that delays the need for insulin shots, blood-sugar monitoring and diet modifications by years, and a new mRNA therapy that would help thousands of patients affected by cystic fibrosis to treat the underlying cause of the disease.
These advancements are amazing, and they bring hope to patients struggling with these chronic, life-threatening diseases.
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But these drugs are only effective in helping those living with chronic illnesses if they can access them. And the biggest barrier to accessing medications is often cost.
Until recently there had been at least one solution: pharmaceutical manufacturers and nonprofits stepped in to support patients and families with copay assistance savings programs, which help reduce out-of-pocket payments for medication and treatment. The savings provided by the programs were intended to be put towards a patient’s insurance deductible, allowing them to hit their out-of-pocket maximum and have insurance cover the rest of the cost.
A constituent with cystic fibrosis recently informed me that beginning a few years ago, insurance companies and pharmacy benefit managers found a loophole in laws meant to ensure people have access to life-saving medicine by categorizing new treatments as “nonessential,” even though for almost 80% there are no generic options available. Insurers don’t have to count funds given by third parties for “nonessential” drugs towards their customers deductible. Mind you, they are still happy to accept the money from assistance programs to support patients, but they then force patients to pay thousands more to reach their out-of-pocket maximum.
That’s unconscionable.
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This latest scheme has not gotten a lot of media attention because most people impacted don’t know their health plan has a co-pay accumulator or maximizer program until they get hit with a surprise bill showing they owe money after they thought they’d already satisfied their deductible. That’s a horrifying prospect, and not being able to continue to use the best treatment modern medicine has found for their illness is even more so.
That’s why it is time to update our laws to prohibit insurers and pharmacy benefit managers from continuing this practice and enable patients to access and afford the lifesaving medications they need to manage their chronic illness.
Fortunately, there is language that has been introduced in Congress with bipartisan support — H.R. 5801, The Help Ensure Lower Patient Copays Act would fix federal laws to protect patients and take insurance companies and pharmacy benefit managers to task for unfair practices like co-pay accumulator policies.
Living with a chronic illness is hard enough. Insurers and pharmacy benefit managers shouldn’t be standing in the way of patients affording lifesaving new treatments with co-pay accumulator and similar schemes.
This article originally appeared on The Providence Journal: Loophole is hurting patients' ability to afford new treatments | Opinion Column
