Opinion: Legislature Should Ban Insurance Language that Makes Vital Medications Unaffordable

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As a physician, when a patient comes to me with an issue or illness that can be treated or even cured, my priority is to make sure they receive the correct and most effective treatment or medication. Unfortunately, I am often forced to include another consideration in what I prescribe: a patient’s ability to afford the medication. 

The most effective medication is the one that my patients can access and afford.  What good is it to prescribe something if patients can’t afford to fill the prescription, or if they are forced to ration it?  Being able to afford ongoing medications is lifesaving for patients suffering from a chronic illness. 

It’s incredible to see the new discoveries and advancements in medicine over the past few years that allow us to treat and manage formerly unmanageable, incurable or even fatal chronic disease. In the last few years, there have been over two dozen new, FDA-approved treatments for cancer; new devices to monitor and administer insulin to diabetes patients; and even a new therapy for people born with cystic fibrosis that could add decades to a patient’s life expectancy.  Unfortunately, insurers don’t want to be on the hook for the high costs of these newer treatments, so they inserted “copay accumulator” language into health plans to shift more of the cost onto patients, which in turn, forces patients to choose whether to prioritize their health or other basic necessities.

Plans that contain a copay accumulator prohibit patients from applying any financial assistance they receive for prescriptions toward their deductible or out-of-pocket payments.  Why does this matter? For years nonprofits and pharmaceutical manufacturers attempted to bridge the gap between high prescription prices and what patients could afford, by creating copay assistance programs that provided coupons and vouchers to help reduce or eliminate patient out-of-pocket costs. These financial assistance programs still exist — and patients still try to utilize them — but the assistance goes straight into insurers pockets instead of helping patients.

This exposes chronically ill patients to costly, ongoing charges for their prescription drugs on top of having to pay for other health care coverage they (or their families) may need during the year. As a result, many patients might find themselves forced to walk away without their medication. Nationwide,  20 to 30 percent of medications go unfilled and approximately 50 percent of chronic disease medications are not taken as prescribed. The Annals of Internal Medicine estimate this drop in medical adherence is responsible for approximately 125,000 deaths nationwide. This cannot continue.

California’s legislature has a distinguished history of enacting laws that make a meaningful difference in the lives of those who live in the state. I urge members of the California Legislature to support AB-874 by Assemblymember Dr. Akilah Weber, which would end this unscrupulous scheme and count funds from copay assistance programs toward an insurer’s out-of-pocket maximum or deductible. The health and well-being of our patients and communities should not be subject to the arbitrary decisions of insurance companies.

Dr. Sion Roy is a member of the Santa Monica College Board of Trustees, a cardiologist, and Past President of the LA County Medical Association. 

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