Fix insurance

High out-of-pocket costs block people’s access to appropriately prescribed medicines, even when their own insurance plan acknowledges a treatment is right. That’s not insurance!

Insurance should cover prescribed treatments without high out-of-pocket costs. Otherwise, what are premiums for?

Most of us pay for health insurance for many years while we’re healthy so that we can afford and access appropriate treatments when we get sick or injured.

Yet many insurance plans still charge high out-of-pocket costs not everyone can afford for prescription drugs and other vital treatments – even those specifically authorized by their plan.

In the case of novel, expensive medicines, high out-of-pocket costs unfairly burden the sick with incentivizing innovation even though those medicines will one day become generic and benefit all of us. We should pay for them together, out of the premiums we all pay.

In the case of medicines that already have gone generic, some plans (PBMs) still make patients pay high list prices, more than the drug actually costs the plan, claiming that the extra money patients are paying helps offset premiums for everyone. But the sick subsidizing the healthy is the opposite of insurance.

Let’s reform insurance so that we can pay for all of this innovation together – without high out-of-pocket costs. That’s how we fix the root of the affordability problem not just for today’s medicines but also tomorrow’s.

We need insurance reform.

Out-of-pocket costs can be deadly.

“The researchers [found] that a simple $10 increase in cost-sharing, which many would consider a small amount of money, led to about a 23 percent decrease in drug consumption. Worse, they said it led to an almost 33 percent increase in monthly mortality. In other words, making seniors pay $10 more per prescription led to people dying.”
—The New York Times: What’s Wrong With Health Insurance? Deductibles Are Ridiculous, for Starters.
Coverage denials leave even the insured without care.

“Insurers’ denial rates — a critical measure of how reliably they pay for customers’ care — remain mostly secret to the public. Federal and state regulators have done little to change that.”
—ProPublica: How Often Do Health Insurers Say No to Patients? No One Knows.
Insurers regularly overcharge and undercover their beneficiaries.

“Patients who take pre-exposure prophylaxis (PrEP), a medication that prevents HIV, should not be paying anything out of pocket for the drug — or for any blood work or doctor visits associated with getting PrEP…. but some patients are getting hit with bills anyway.”
—Axios: When you're charged a copay you shouldn't owe

Our Solution

Cap out-of-pocket costs.

Cap out-of-pocket costs at $2,000 and smooth them over the year for all marketplace plans.

Prevent abuse of prior authorization.

Prior authorizations should be real-time, electronic, and frictionless, serving to confirm that a prescription is appropriate, not as many plans use them today as time-consuming obstacles to discourage doctors from prescribing even appropriate medicines.

Expand access to insurance.

Extend subsidies for individuals and families buying insurance through the Affordable Care Act.

RELATED RESOURCES

Affordability & Innovation.

At No Patient Left Behind, we believe that for insurance to really be insurance it should fully cover the drugs your doctor prescribes when you’re sick – without high out-of-pocket costs.

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