Most adult Americans take at least one prescription drug, and for too many, getting that prescription filled means battling the very system that’s supposed to help them.
Insurance denials have become alarmingly routine. A recent study found that 70% of commercially insured patients face initial claim rejections for new branded medicines. And even when patients manage to access treatment, affordability remains a major challenge: nearly 60% of U.S. adults worry about being able to pay for their medications.
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At the center of this crisis are the abusive practices of corporate middlemen. America’s vertically integrated mega-insurers and their subsidiary pharmacy benefit managers have grown to control virtually every aspect of healthcare access and affordability and deliberately erected administrative barriers that delay care and inflate costs — barriers felt most acutely by patients managing serious chronic conditions.
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Although the Trump administration is taking steps to investigate insurer and PBM practices, it’s time for it to crack down on these bad actors once and for all.
Insurers and PBMs frequently force patients to jump through a maze of hoops to access treatment.
Take prior authorization. Many insurers require that providers obtain their approval before prescribing or supplying a medicine. For patients with chronic conditions, this requirement can be especially burdensome — 4 in 10 insured adults within this patient population say prior authorization is among their greatest healthcare challenges.
Then there are copay accumulator programs. Large insurers and PBMs often exclude manufacturer copay assistance from counting toward a patient’s deductible or out-of-pocket maximum. That allows them to effectively “double dip,” pocketing the copay assistance while still collecting payments from patients. Copay assistance is there to benefit the patient, not the insurance corporation.
These middlemen also designate certain drugs as “non-essential” to exploit drugmakers’ copay assistance programs. By doing so, they dodge certain federal cost-sharing protections and pocket additional funds while squeezing patients.
All of these barriers create major financial challenges for patients — in many cases, they’re losing out on programs that pharmaceutical companies have set up to make their medicines more affordable.
Beyond straining Americans’ wallets, insurance practices disrupt crucial doctor-patient relationships and put patient health at risk.
Indeed, some medical practices report spending roughly 14 hours each week handling the paperwork that prior authorization alone requires. That’s valuable time that should be spent caring for patients. Instead, doctors are forced to justify their medical decisions to corporate middlemen who second-guess their judgment.
The effects on patient care are significant. Nearly 95% of doctors say that prior authorization delays access to necessary care. Eighty percent cite patients abandoning necessary treatments due to prior authorization barriers. And 1 in 3 physicians report that insurer delays led to severe events, including hospitalizations and permanent impairments.
For patients living with chronic conditions, those delays are especially dangerous. Their health depends on timely, consistent access to treatment. Just one missed dose or treatment can have devastating — even fatal — consequences.
Consider patients battling cancer. Each week of delayed treatment can increase the risk of death by 1% to 3%. Still, about 75% of adult cancer patients have had to navigate prior authorization at least once in recent years. In many cases, their already-burdened families must step in to help doctors secure access to life-saving care.
Or consider people living with HIV. They need continuous access to antiretroviral therapy to keep the viral load in their bodies low. Otherwise, they could develop AIDS, effectively turning a manageable condition into a death sentence. Higher viral loads increase the risk of transmission to other people as well — a major public health concern.
Just recently, a report from the HIV Medicine Association confirmed that prior authorization requirements create “dangerous delays and disruptions in care” for HIV patients.
The Trump administration, through Federal Trade Commission investigations and Department of Labor transparency regulations, has begun taking steps in the right direction toward insurance and PBM reform. However, a much bigger opportunity exists to improve healthcare for Americans and lower costs at the same time. President Donald Trump and his administration can do more to stand up for patients and protect their access to life-saving treatment.
It could do so by enforcing or codifying a 2023 court decision requiring insurers to apply manufacturer copay assistance toward patients’ cost-sharing obligations. The ruling prohibits insurers from implementing copay accumulators for drugs without generic alternatives — a major victory for patients that should now be cemented into federal policy.
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Alongside that effort, the administration must ensure that all drugs covered by employer health plans are designated “essential health benefits,” as is already required in the small-group and individual health markets. It can also champion bipartisan legislation such as the Help Ensure Lower Patient Copays Act, which would rein in insurers’ and PBMs’ abuse of “non-essential” drug designations and ensure copay assistance actually lowers patients’ out-of-pocket costs.
Trump has rightly made reducing healthcare costs and barriers to care a priority. He can further deliver on that promise by curtailing these price-gouging insurance middlemen schemes and putting patients first.
Carl Schmid is the executive director of the HIV+Hepatitis Policy Institute.
