During a recent swing through the Midwest, President Barack Obama noted that, thanks to the Affordable Care Act, America has moved on from the days in which “people could be denied healthcare based on pre-existing conditions.”
The ACA has indeed made great progress on this front. But the fight to end insurance
The Obama administration has an opportunity to end these practices by making sure the ACA’s strong nondiscrimination provisions are implemented in a way that protects patients. As they finalize this provision, which is now pending at the White House, it’s crucial that federal officials address the discriminatory practices that continue to plague our insurance system. If they don’t, one of the ACA’s most important promises will be left unfulfilled.
There’s no question that the ACA has brought us closer to an insurance market that is free of discrimination based on race, sex, age, or disability. But not all beneficiaries are protected from unfair insurance practices. Indeed, insurers still have numerous ways of imposing undue costs and burdens on ACA exchange customers — particularly those suffering from chronic and serious health conditions.
One such tactic, known as “adverse tiering,” involves plans placing all of the medications commonly used to treat a condition in the highest cost-sharing category, or “tier.”
The goal is to discourage patients who need certain medicines from enrolling in the plan due to prohibitively high out-of-pocket expenses. My organization, the AIDS Institute, has called out many plans for placing all HIV or hepatitis medications on the highest tier and charging patients co-insurance as high as 50 percent.
According to a study from Harvard’s T.H. Chan School of Public Health, this strategy is disturbingly common. Researchers looked at exchange plans in a dozen states, and found that a quarter of those policies featured adverse tiering for commonly-prescribed HIV medications. Patients enrolled in such plans faced average annual costs of $4,892 per drug — more than three times the cost paid in plans that do not adversely tier.
Cumbersome medication management tools also block access to medicines for patients with chronic and serious health conditions. For instance, excessive prior authorization requirements force doctors to seek permission from insurers before treating their patients with certain medicines. A related strategy, known as step therapy, forces patients to try and fail to control their conditions with less costly medicines before they can access more expensive treatments. Another practice forces patients who are stable on one medication to switch mid-year to another for non-medical purposes.
These practices amount to deliberate discrimination
The U.S. Department of Health and Human Services doesn’t dispute this fact, admitting that plan designs that raise the costs of prescription drugs for certain illnesses “discriminate against, or discourage enrollment by, individuals who have those conditions.”
Those with chronic and serious diseases are also disproportionally affected by the narrow provider networks of many ACA plans. Researchers at the University of Pennsylvania estimate that, in 2014, 41 percent of all exchange plans included a quarter or less of local doctors in their provider networks.
By limiting access to physicians — and particularly specialists — current plan designs ensure that certain patient populations have few care options, making them less likely to enroll in these plans or receive treatment if they are enrolled.
These and other practices run contrary to the ACA’s stated mission of ending healthcare discrimination. HHS regulators can close these loopholes by clarifying the law’s intent and spelling out nondiscrimination provisions in greater detail. In particular, efforts to block access to needed medications — including adverse tiering, step therapy, prior authorization requirements, and medication switching — should be defined as discrimination.
The same goes for narrow provider networks, as well as all forms of excessively high cost-sharing directed specifically at sicker patients.
Moreover, officials must make clear that patients with chronic and other serious health conditions — and not only those considered “disabled” under the Americans with Disabilities Act — are protected by the ACA’s nondiscrimination provision.
Discrimination in the insurance market may be rarer under the ACA. But, as the last few years have shown, insurers have still found ways to avoid covering the most vulnerable patients.
As the Obama administration finalizes the nondiscrimination rule, it has an opportunity to eliminate unjust and discriminatory insurance practices, and make good on the ACA’s promise of affordable care for all.
Carl Schmid is the Deputy Executive Director of The AIDS Institute.Thinking of submitting an op-ed to the Washington Examiner? Be sure to read our guidelines on submissions.
