Exchange insurance plans may make second-class citizens of patients with chronic disease, a recent Peter Pitts commentary contends. As research from both Avalere Health and Milliman finds, insurance plans sold through a state or federal exchange disproportionately apply cost-sharing formulas to cancer patients – burdening many with unmanageable out-of-pocket costs. Public outcry over what some characterize as discrimination by insurers has prompted federal complaints that could soon proliferate.
Ironically, access for patients with pre-existing conditions such as cancer prevailed as one of the Affordable Care Act’s flagship selling points. So did the promise of affordable care for all. And, true to the letter of the law, participating insurers do offer coverage for cancer patients and those suffering chronic disease, applying limited premium increases to reflect the expense of these patients’ conditions. But the bulk of cancer patients’ medical costs take the form of medication expenses, and in this arena insurers face fewer statutory restrictions.
Insurance specialty tiers provide a structure for offsetting the cost of cancer care. Through drug tier cost sharing, cancer patients who need more complex, more expensive medications pay both a higher amount and a higher percentage of their drug expenses.
A recent Milliman study found that patients with Silver plans (the most common plan option) paid as much as 230 percent more out of pocket for medications than they would in an employer-sponsored health plan. Silver plans are also more likely to require combined deductibles, which require roughly 130 percent higher patient cost sharing by lumping prescription and health benefit deductibles together. Because cancer and other chronic disease patients need more – and more expensive medications – these factors affect them disproportionately.
Avalere Health issued similar findings. According to Avalere, more than one fifth of Silver plans burden patients with 40 percent cost sharing on drugs for cancer and other high-cost diseases.
The resulting discrepancy in cost and coverage, critics argue, is akin to discrimination. The AIDS Institute recently filed a federal discrimination complaint against four Florida insurers for structuring their drug benefit programs to deter AIDS patients from purchasing coverage from them. It remains to be seen if cancer and other chronic disease advocacy groups will follow suit.
As anti-discrimination complaints take shape, cancer patients continue to search for comprehensive coverage – including coverage that provides life-saving therapies at realistic costs. But until fairer options exist, these patients face difficult decisions about personal finances and quality of life.