Americans need protection from predatory medical insurance practices Expensive health care continues to create barriers in Pennsylvania and beyond.

Pennsylvania families are navigating a treacherous landscape of confusing and predatory insurer practices.

Today, health insurers and pharmacy benefit managers (PBMs) in our state have free rein to block the value of copay assistance from counting toward patient deductibles, a practice that puts vulnerable patients on the hook for greater costs, often without warning. As families struggle under the burden of medical debt and a complicated open enrollment landscape, Pennsylvania legislators must support federal legislation to ensure copay assistance counts and help patients afford and access their treatments.

The high cost of health care continues to pose a barrier to care in Pennsylvania and beyond. A recent Kaiser Family Foundation poll found that 44% of insured patients worry about being able to afford their deductible before their insurance starts paying for care, and half of U.S. adults said they would not be able to afford an unexpected medical bill of $500. For many, worries about medical debt have become a daily reality. Kaiser Health News estimates that more than 1 million Pennsylvanians have medical debt already in collections.

COPAY ACCUMULATOR POLICIES

Insurers have only worsened the situation by providing inconsistent coverage for their beneficiaries. To provide a lifeline for Pennsylvania patients, drug manufacturers developed copay assistance programs, helping patients afford their medications when they have no other means to do so and for which generic equivalents do not exist.

In fact, 79% of brand medications with available copay assistance today do not have a generic equivalent, and a recent study found that the use of copay assistance led to a 24% annual reduction in out-of-pocket spending between 2015-2021 and increased drug use, improving health outcomes.

But more often, insurers and PBMs have implemented schemes called “copay accumulator adjustment programs” that prevent the value of the copay assistance from counting toward a patient’s deductible. Faced with unexpectedly high costs at the pharmacy counter, patients impacted by these policies are less likely to adhere to treatment which can lead to worsened health outcomes, increased hospitalizations and greater costs to the health care system.

Copay accumulator policies disproportionately impact communities of color. Research has found that non-white patients were 31% more likely to be “exposed” to copay accumulators than white patients, exacerbating preexisting racial disparities for those who are managing a complex or chronic condition. Take, for example, the field of liver disease, the ninth-leading cause of death among Black Americans. Black men are 60% more likely to develop liver cancer than white men and Black women are 40% more likely to die from liver cancer than white women.

Despite these alarming findings, Black Americans are less likely to receive accurate and timely diagnosis for liver conditions. Insurer and PBM policies only worsen the existing diagnostic delays and unequal access to treatments for patients of color.

Thousands of patients in Pennsylvania alone are at risk of experiencing the health and financial impacts of a copay accumulator policy. A recent report from the AIDS Institute found that 7 out of 11 health plans in Pennsylvania have copay accumulator adjustment policies. To mask the patient impact of these policies, insurers and PBMs purposely use deceptive language that leads patients to believe such provisions will actually benefit them.

NEED FOR FEDERAL ACTION

As patients face the real-life consequences of copay accumulators at the pharmacy counter, state legislatures have started to take notice. To date, 19 states, Washington, D.C., and Puerto Rico have implemented legislation to ensure that copay assistance counts toward a patient’s out-of-pocket costs. In Pennsylvania, such legislation was introduced during the 2021-22 session, but without federal action, millions of patients remain vulnerable.

This year, bipartisan members in the U.S. House of Representatives and Senate introduced the Help Ensure Lower Patient (HELP) Copays Act, which would institute a federal prohibition on copay accumulator programs and close a federal loophole that allows insurers and PBMs to designate cost-sharing for certain medicines as not applicable toward patient out-of-pocket limits.

These bills have broad bipartisan support from 120 legislators across chambers, including Pennsylvania’s own U.S. Reps. Brian Fitzpatrick, Chrissy Houlahan, Susan Wild, Madeleine Dean and Dan Meuser. I urge Sens. Bob Casey Jr., John Fetterman and all members of the Pennsylvania congressional delegation to join them and support the HELP Copays Act to ensure Pennsylvanians can access their prescription medications.

By supporting this legislation, our legislators can provide relief to families in our state who are struggling with medical bills and the challenges of staying healthy.

Suzanna Masartis is the CEO of the Community Liver Alliance, a nonprofit in Pittsburgh.