Exchange plans fail autoimmune patients

Virginia Ladd

The latest legal wrangle over the Affordable Care Act raises the prospect that millions will find themselves unable to afford health insurance. Just as vexing, though, is the quality of coverage insurers are currently offering.

Even with generous federal subsidies, many available plans make paying for medications to treat cancer, HIV/AIDS, autoimmune diseases, bipolar disorder and other serious conditions totally unaffordable. If the Affordable Care Act doesn’t help the most vulnerable Americans pay for treatment, who is it helping?

A report by the research group Milliman found that 46 percent of all enrollees with a Silver plan — the most popular level of coverage — have a single, combined deductible for medical and pharmacy benefits. As a result, it’s not uncommon for those who are covered to pay more than $2,000 out of pocket before they get any prescription drug coverage. And for the Bronze level plans, the deductibles average more than $4,000.

Compounding this problem is the high cost-sharing involved in most plans. Typically, insurance plans have four or five cost-sharing tiers. The lowest tier might have a small co-pay of $15 for prescription drugs, while the highest tier might require patients to pay 40 percent or more of the actual cost of the medication.

For serious conditions, such cost-sharing can run patients hundreds of dollars per month or more.

A new report by Avalere health analyzed cost-sharing in Affordable Care Act plans for all brand name and generic drugs within 19 different classes of prescription drugs used to treat specific illnesses. The results are troubling, to put it mildly.

A shocking number of vital drug treatments are in the top cost-sharing tier for enrollees. In seven of the classes, one in five Silver plans require coinsurance of 40 percent for all covered medications.

Additionally, Avalere reports over 60 percent of Silver plans also placed treatments for certain types of cancer in the highest cost-sharing tier. More than 60 percent of Silver plans put all medicines for treating autoimmune diseases such as multiple sclerosis, rheumatoid arthritis and Crohn’s disease in the top tier.

The cost associated with non-adherence to prescription drug regimens is particularly problematic with regard to autoimmune diseases. In many cases, these conditions can be managed quite effectively with drugs.

Autoimmune diseases are responsible for $100 billion in direct medical costs annually, and much of that cost is because patients have trouble staying on top of their treatments and end up in hospitals.

By making autoimmune drugs unaffordable, these insurance plans could make other health care costs explode. What’s more, 75 percent of those suffering from autoimmune diseases are women.

The top priority of the Affordable Care Act is right there in its name: affordability.

Instead, it is putting basic health care out of reach for many of the sickest and most vulnerable Americans.

Virginia Ladd is the president and executive director of the American Autoimmune Related Diseases Association, headquartered in Eastpointe.