Today many more Californians have access to health care coverage under the Affordable Care Act, however many premium-paying patients who are covered still struggle with out-of-pocket costs. Some practices by providers and health insurers unfairly burden patients with unmanageable cost-sharing, interfering with access to care people need. AB339 (Gordon), a Health Access sponsored bill moving through the California Legislature, would prevent discrimination against consumers with chronic health conditions and set standards for cost sharing for prescription drugs.
The emergence of very high cost specialty drugs led health plans and insurers to impose high copays and coinsurance on these drugs. Such drugs are often placed on the highest cost tier of a drug formulary (commonly known as the “fourth tier” or the “specialty tier”) with coinsurance of up to 20%, 30% or even 40% as opposed to a fixed co-payment. As a result, Californians with asthma, HIV/AIDS, hepatitis C, cancer, multiple sclerosis, rheumatoid arthritis or other serious conditions can face high out-of-pocket costs and may exhaust their annual out-of-pocket limit of $6,500 with a single prescription in the first month.
The point of AB339 is to get the patient out of the middle of the fight between the health plans and the drug companies by providing basic consumer protections, including a cap of no more than $250 per monthly prescription for most coverage, or $500 for products in the bronze tier.
A recent study by Kaiser Family Foundation found that median liquid assets for a family making over 100% FPL (Federal Poverty Level) is $2,564. This means that drug cost sharing that amounts to $6,500 for a single drug is literally three times as much as most people have in the bank.
Those who face very high drug cost sharing are the sickest among us: individuals with chronic health conditions such as asthma, multiple sclerosis, lupus, HIV/AIDS, and organ transplants. These individuals face numerous health care costs for doctors, lab tests and other drugs in addition to their specialty drug costs.
Studies show that when people can’t afford their prescription drugs they skip doses, split pills in half, or simply fail to pick up their prescriptions. A recent California Health Benefits Review Program (CHBRP) analysis also shows that poor adherence to prescription drug therapy for chronic conditions results in worse health outcomes, higher rates of hospitalization, and more emergency department visits. CHBRP also found that reducing cost barriers for high cost and/or specialty drugs would result in important health and quality of life improvements for people with serious, chronic conditions.
The consumer protections in AB 339 align with the standardized benefits recently adopted by Covered California for 2016 qualified health plans. AB339 would ensure millions more Californians have reliable access to needed medications— in addition to those in Covered California, millions more in employer coverage would have this protection.
AB 339 passed the Senate Health Committee on July 15, 2015 with a party line vote of 7-2. It is scheduled to be heard next in Senate Appropriations on Monday, August 17, 2015.