Exchange Open Enrollment Ends, But Rx Access Concerns Linger

February 16, 2015

by Amanda Conschafter, blog editor

Open enrollment at HealthCare.gov ended February 15, initiating the program’s second year of offering health insurance to Americans. But have patients with high-cost or chronic diseases gotten a fair shake? And do patients understand the policies they’ve purchased – including the out-of-pocket costs they’re expected to shoulder? Some research suggests not.

In fact, a new study from Avalere Health highlights trends toward discriminatory policy design. The analysis of 2015 plan offerings revealed that an increasing number of plans place all medications for some chronic diseases – including even the generic versions of these drugs – on the highest, or specialty, tier. Specialty tier status requires high out-of-pocket costs for patients, with coinsurance rates of 30-40 percent. The study also noted that the practice of placing all medications for a specific disease on the highest tier doubled for AIDS medications.

Discrimination concerns are nothing new. Last year the AIDS Institute filed a discrimination complaintwith the Office for Civil Rights against four Florida insurance companies. The group argued that these insurers required “exorbitant” cost-sharing for vital medications, effectively encouraging AIDS patients to seek coverage elsewhere. And more than 300 patient groups submitted a letter to Health and Human Services Secretary Sylvia Matthews Burwell to complain of similarly discriminatory practices.

Though some groups worry about narrowing physician networks, which reduce patient choice, most concerns center on access to necessary medications.   The Affordable Care Act prohibits insurance companies from increasing premiums substantially for patients with pre-existing conditions, such as chronic or serious illnesses. So insurers offset their expenses by excluding certain high-cost drugs from their formulary – or by using specialty tier structures to shift the cost back onto the patient.

But patients may struggle to understand their drug coverage and cost-sharing requirements when they purchase coverage through an exchange. One study found that HealthCare.gov fails to report cost-sharing information for all varieties of specialty tier structures, leaving certain patients in the dark about their cost-sharing requirements.

Another study cited the lack of clear and accessible formulary information. It also noted that few state exchange websites offer cost-calculating tools, which would allow patients to do the math on how much they would owe under various plan options.

HHS reported that nearly 10 million people signed up for coverage through the federal or a state exchange program. But the ability of those plans to deliver essential medications at a price patients can afford remains to be seen.

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