To fight drug affordability crisis, Trump administration must crack down on middlemen

Most adult Americans take at least one prescription drug, and for too many, getting that prescription filled means battling the very system that's supposed to help them.

Insurance denials have become alarmingly routine. A recent study found that 70 percent of commercially insured patients face initial claim rejections for new branded medicines. And even when patients manage to access treatment, affordability remains a major challenge: nearly 60 percent of U.S. adults worry about being able to pay for their medications.

At the center of this crisis are the abusive practices of corporate middlemen. America's vertically integrated mega-insurers and their subsidiary pharmacy benefit managers (PBMs) have grown to control virtually every aspect of healthcare and deliberately erected administrative barriers that delay care and inflate costs – barriers felt most acutely by patients managing serious chronic conditions.

Take prior authorization. Many insurers require that providers obtain their approval before prescribing or supplying a medicine. For patients with chronic conditions, this requirement can be especially burdensome – four in 10 insured adults within this patient population say prior authorization is among their greatest healthcare challenges.

Then there are copay accumulator programs. Large insurers and PBMs often exclude manufacturer copay assistance from counting toward a patient's deductible or out-of-pocket maximum. That allows them to effectively "double dip," pocketing the copay assistance while still collecting payments from patients.

These middlemen also designate certain drugs as "non-essential" in order to exploit drugmakers' copay assistance programs. By doing so, they dodge certain federal cost-sharing protections and pocket additional funds while squeezing patients.

The effects on patient care are significant. Nearly 95 percent of doctors say that prior authorization causes delays in accessing necessary care. And one in three physicians reports that insurer delays led to severe events, including hospitalizations and permanent impairments.

For patients living with chronic conditions, those delays are especially dangerous. Their health depends on timely, consistent access to treatment.

Consider people living with HIV. They need continuous access to antiretroviral therapy to keep the viral load in their bodies low. Otherwise, they could develop AIDS. Higher viral loads increase the risk of transmission to other people as well – a major public health concern.

President Trump and his administration can do more in standing up for patients and protecting their access to life-saving treatment.

It could do so by enforcing or codifying a 2023 court decision requiring insurers to apply manufacturer copay assistance toward patients' cost-sharing obligations.

Alongside that effort, the administration must ensure that all drugs covered by employer health plans be designated "essential health benefits," as is already required in the small group and individual health markets.

They can also champion bipartisan legislation like the Help Ensure Lower Patient (HELP) Copays Act, which would rein in insurers' and PBMs' abuse of "non-essential" drug designations and ensure copay assistance actually lowers patients' out-of-pocket costs.

President Trump has rightly made reducing healthcare costs and barriers to care a priority. He can further deliver on that promise by curtailing these price-gouging insurance middlemen schemes and putting patients first.

This piece originally ran in the Washington Examiner.

Carl Schmid is the executive director of the HIV+Hepatitis Policy Institute.