National Kidney Month: The Human Cost of Insurance Barriers
By: Priscilla VanderVeer
This is the second in a series of posts recognizing March as National Kidney Month. You can read the first post here.
Those who know me know I have feelings about health insurance companies and their practices. That’s because I’ve lived most of my life with an incurable and serious chronic disease.
I’ve been a college student enrolled in Medicare before Part D prescription drug plans or Medicare Advantage helped pay for things traditional Medicare doesn’t cover (which is a lot).
I’ve qualified for some support from Medicaid, only to lose that when I earned just a few dollars above the income limits.
I’ve been terrified about losing my job and its accompanying health insurance benefits (before the Affordable Care Act, if you had any gap in coverage, an insurer could deny you for having a preexisting condition).
I’ve spent countless hours going over complicated health plan options and drug formularies, doing math to determine the best plan to meet my needs in good times and bad.
And I’ve paid tens of thousands of dollars out of pocket when my insurance coverage failed to pay for the care I needed to survive.
None of this is shocking to anyone who has a serious illness or cares for someone with one. If we all had a nickel for every minute we’ve spent on the phone arguing with health insurers and their pharmacy benefit managers, well, we wouldn’t need to call them anymore because we could just pay for it ourselves.
We have a system where the sickest among us subsidize the healthiest, and where coverage gets worse each year, despite ever-increasing premiums.
At NPLB, our focus is on common-sense ways to make medicines more affordable to the people who need them. Why? Because medicines are what keep people out of hospitals, avoid costly complications, and help us live as well as we can. They’re the best deal in health care, and the only part of the system where costs go down over time as medicines face competition and go generic.
Here’s how we can make drugs more affordable:
Cap Out-of-pocket Costs: No one should pay more than $2,000 per year out of pocket for their medicines and those costs should be spread over the year for all ACA plans. Today, less than 6% of ACA enrollees even exceed $2,000 in annual drug spend, meaning this would provide real relief at minimal cost.
Cover Medicines from Day One: When plans claim to cover a medicine that has been appropriately prescribed, they should cover it from day one of the plan year and not require patients to reach a deductible before coverage kicks in.
Prevent Prior Authorization Abuse: Prior authorizations should be real-time, electronic, and frictionless. Use them as a tool to help confirm a prescription is appropriate, not to put up bureaucratic, time-consuming obstacles that discourage doctors from prescribing medicines and patients from trying to get appropriate medicines.
Expand Access to Insurance: Reinstate subsidies for individuals and families buying insurance through the Affordable Care Act exchanges.
Tie Out-of-pocket Costs to Net Prices: Until first-dollar coverage is universal, any patient costs linked to a drug’s price should be based on the net price their insurer and PBM pay rather than the list price, which means passing rebate savings through to patients at the pharmacy counter.
For people living with chronic disease, health insurance shouldn’t be another hurdle. We should spend our energy and focus fighting for the best lives we can, not fighting against insurance companies.
To learn more about how to #FixInsurance so it works as it should, visit https://www.nopatientleftbehind.org/fixinsurance.