Prior to serving in the Alabama Legislature, I earned a scholarship to North Carolina State University where I enrolled as a college athlete and eventually embarked upon a career as a professional football player for the Canadian Football League and Arena Football League. These experiences helped give me a passion for health, nutrition, and holistic wellness. Since serving in the Legislature, I hear often from constituents about the toll that the rising cost of healthcare has taken on family, friends, and neighbors.
I recently spoke with a physician that takes care of patients with chronic medical conditions who stated, “Affordability of medication is something I deal with every day. Unfortunately, drug costs continue to increase for my patients, and patients who cannot afford medications end up being readmitted into the hospital to treat the same chronic illnesses. I utilize drug assistance programs even for my patients who have insurance with drug plans because the medications can be so expensive.”
My friend went on to say, “If the co pay accumulator goes into effect, this will create an even greater barrier for the already, at risk and vulnerable population, including the elderly, those with chronic health conditions and other disabilities. All leading to increase morbidity and mortality in our state that is struggling in this area.”
Specialty medication has come a long way, allowing these same individuals to lead longer and healthier lives. As a result of these advancements, access and affordability of these specialty medications are imperative, and just the right thing to do for patients.
Over the past few years, the Food and Drug Administration (FDA) has approved more than a dozen new treatments or therapies to treat or cure many types of cancers. And new therapies have been approved by the FDA to help treat hereditary diseases the begin shortly after birth like cystic fibrosis. Unfortunately, the prices for specialty medication used to treat cancer, diabetes, sickle cell, cystic fibrosis, and other complex chronic illnesses keep rising leaving patients in a lurch—they either find ways to afford the cost or gamble with their health. Our community and the people of Alabama deserve solutions.
Until recently there had been some recourse for families looking for a help affording their healthcare. Patient advocacy groups, non-profits and drug manufacturers created copay assistance savings programs, which helped reduce out-of-pocket payments for medication and treatment.
But about five years ago, pharmacy benefit managers (PBMs) and health insurers decided to exploit a loophole to try and avoid covering the cost of newer drugs and treatments. The inserted “copay accumulator adjustment” language into the fine print of all Alabama plans offered in the ACA marketplace that allowed them to not count third party assistance of a “non-essential” drug towards a patent’s co-pay or deductible. Try telling a family that the medicine they take to be able live comfortably day to day is “non-essential” when there are no generic alternatives, as is the case for almost 4 out of every 5 drugs that fall under the program.
So why hasn’t there been a lot of talk about this problem that could affect hundreds of thousands of people in our state? Because most people don’t know this insidious gimmick exists until they receive a bill months later for care or medicine after they thought they had hit their out-of-pocket maximum.
We need to update our state laws to prohibit insurers and PBMs from continuing this practice and enable patients to access and afford the lifesaving medications they need to manage their chronic illness. Thankfully there is legislation that has been introduced on the federal level in Congress with bipartisan support: HR5801, the Help Ensure Lower Patient (HELP) Copays Act would amend the Public Health Service Act to apply additional payments, discounts, and other financial assistance towards the cost- sharing requirements of health insurance plans, and for other purposes. I am hopeful that our congressional delegation will pass this needed legislation to protect patients.