The District of Columbia was one of the first jurisdictions in the country to fully implement the Affordable Care Act, in order to provide District residents quality and affordable healthcare. Through an expansion of Medicaid and access to private insurance through DC HealthLink, our city’s healthcare marketplace, in addition to those covered by their employer and other programs, all District residents should be able to access healthcare.
But despite the goal and intentions of the Affordable Care Act and the District’s elected officials, two of the major insurance companies offering plans in the District are now instituting programs that will make it more difficult for patients to afford their drugs. CareFirst and United HealthCare have quietly placed what are known as accumulator adjustment programs into the back pages of their healthcare plans. These are a new cost-shifting tool that is raising out-of-pocket costs for patients as they pay for their medications.
In order to afford their drugs, many patients take advantage of pharmaceutical financial assistance, in the form of a copay “coupon” card at the pharmacy counter. Assistance programs like this help patients lessen high out-of-pocket costs as they struggle to meet their deductibles and out-of-pocket maximums. For patients with HIV, hepatitis, or those who want to take PrEP to prevent HIV, and chronic conditions like arthritis and cancer, this assistance can help mitigate the up-front costs of lifesaving medications.
Accumulator programs, tucked in into unclear contract language, remove the benefits of manufacturer assistance programs by no longer counting this support toward patients’ deductibles. This leaves patients responsible for the full price of their treatments until they reach their deductible or out-of-pocket maximum, which could be as high as $7,150 for an individual. District patients are thus seeing the price they pay for their drugs dramatically jump at the pharmacy counter without any explanation or adequate education from their insurance companies.
It is well documented that, as the out-of-pocket costs of medications increase, patients are increasingly likely to abandon their treatments at the pharmacy counter. A recent IQVIA study showed as the out-of-pocket cost of treatment rose past $125, over half of patients abandoned their medication at the pharmacy counter. Patients need affordable access and should not fall victim to a benefit design that no longer supports their medical needs.
Like elsewhere across the country, Washingtonians have seen their premiums increase year-over-year. This is in addition to rising deductibles, increased co-insurance, and more and more tiers for specialty medications. These changes to insurance design have made out-of-pocket costs rise for patients, and accumulator programs are another cost-shifting tool that insurers are using to force patients to pay more for their medications.
The District has one of the highest HIV rates in the country and is making every effort to ensure access to antiretroviral treatment. For those who are at a higher risk of HIV, access to PrEP, a drug that prevents HIV, is necessary. But the drugs can only work if people can afford them.
D.C. residents also face other illnesses such as cancer, arthritis, hepatitis C, MS and others that all require medications that offer manufacturer assistance at the pharmacy counter. These new insurance programs run counter to efforts to improve individual and public health in the District.
Insurers are implementing these new questionable policies without beneficiaries knowing about them. CareFirst snuck it into page 111 of a 159-page plan “contract”, while United Healthcare inserted it on page 159 of a 166 page “medical policy.” Because of this lack of transparency, 60 HIV organization recently wrote a letter to D.C.’s insurance commissioner and attorney general asking them to look into these harmful practices. These practices also seem to be violating the ACA cost sharing limits, since the insurers are double-dipping by collecting both the patient cost-sharing and the copay coupons.
CareFirst and United HealthCare – and employers such as Walmart, Home Depot and PepsiCo – should reconsider their decision to institute these programs and end this trend of increased cost-shifting to patients. Patients purchase their insurance with the goal of coverage that will meet their medical needs and help offset financial barriers to care. These programs severely undermine this goal.
Carl Schmid is the Deputy Executive Director of the AIDS Institute.
