Debased Silver

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  • 08/11/2014

From today’s edition of the New York Post …

From HIV to cancer to Crone’s, ObamaCare fails the sick

By Peter J. Pitts

Melanie Thompson and HIV patient Brian Albright look over his medical bills and correspondence with his insurance company in Atlanta. Photo: AP

It turns out ObamaCare didn’t solve the problem of “pre-existing conditions” after all. It made premiums more affordable for people with chronic health conditions that are expensive to treat — but at the price of sticking them with unaffordable co-payments for their medications.

The nonprofit AIDS Institute is suing four Florida health insurers for discriminating against HIV/AIDS patients. The complaint says these patients now face prohibitive out-of-pocket drug costs. Sadly, most of the plans sold via ObamaCare all across the country have similar problems — leaving those with chronic diseases without affordable access to the specialty drugs they need.

The Affordable Care Act limits the degree to which insurers can charge higher premiums for sicker patients. But ObamaCare plans found a way around these rules: impose higher out-of-pocket costs for all or most specialty drugs.

Consider the Florida suit. Carl Schmid, the AIDS Institute deputy executive director, says the plans follow a “pattern where every single [HIV/AIDS] drug for some plans was on the highest tier, including generics.” Under these policies, drug costs for AIDS patients can exceed $1,000 a month.

And Florida’s hardly unusual. A new report from consulting group Avalere Health found that a large majority of all ObamaCare exchange plans include similarly high out-of-pocket costs for patients with certain illnesses.

The breakdown of Silver plans (the most popular category) is particularly revealing. In seven classes of drugs for conditions from cancer to bipolar disorder, more than a fifth of these plans require patients to shoulder 40 percent of the medicine’s cost.

And 60 percent of Silver plans place all drugs for illnesses like multiple sclerosis and rheumatoid arthritis in the “formulary tier” with the highest level of cost-sharing.

Nearly every Silver plan across the country, in fact, puts at least one class of drug exclusively in the top cost-sharing tier. In effect, this leaves patients with a given condition — whether HIV or Crohn’s disease — without a single affordable treatment option.

Pre-ObamaCare, about half the states had a system in place for helping people with pre-existing conditions: state high-risk pool plans, which for years offered government-subsidized coverage to patients with pre-existing conditions. But the Affordable Care Act banned those pools.

So now, with exchange plans failing them, the chronically ill have nowhere left to go.

Allies of the insurance industry blame the drug companies for the high price of certain medicines. AARP policy adviser Leigh Purvis, for instance, says cost-sharing levels “wouldn’t be so high if the prices of drugs weren’t so high.” Health-policy advocate John Rother, meanwhile, claims that “reducing price is something [drug] companies could do tomorrow.”

But drug prices aren’t arbitrary. The average biopharmaceutical therapy takes $1.2 billion and anywhere from 10 to 15 years to bring to market. Firms must charge high prices for certain brand-name drugs to make back this substantial investment with enough left over to fund research into the next generation of treatments.

And while insurers like to complain that sophisticated therapies cost too much, they tend to ignore the far higher costs of denying these medicines to patients.

Increased co-pays result in “non-adherence,” failure to take prescribed medications. And that equals increased rates of hospitalization, chronic heart failure and premature death.

And this adds to health outlays: According to a recent study in the Annals of Internal Medicine, non-adherence costs the US health system from $100 billion to $289 billion a year.

In short, by making needed medications unaffordable — and by failing to cover newer, targeted therapies — insurers are jeopardizing patient health. And far from saving money, cutting off access to specialty drugs actually increases long-term health costs.

Specialty medications need to be treated as equivalent to other essential medical services — not as some luxury that only the wealthy can afford. But the ObamaCare law has only made the problem worse than ever.

Peter J. Pitts, a former Food and Drug Administration associate commissioner, is president of the Center for Medicine in the Public Interest.


Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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