Hawaii Health Connector is Hawaii's Obamacare exchange
Hawaii Health Connector is Hawaii's Obamacare exchange
Hawaii Health Connector is Hawaii’s Obamacare exchange

By Jasmine Greenamyer – Colon cancer will claim more than 50,000 American lives this year. One in 20 people will be diagnosed at some point in their lives.

Thanks to better screening and new treatments, the death rate from colon cancer has been dropping for more than 20 years. But even the best screening and treatment can’t help those unable to afford health care.

The Affordable Care Act was designed to help make sure patients could receive the care they need. But it’s failing America’s most vulnerable patients. Congress must make sure the Affordable Care Act lives up to its name and enables people to access the health coverage they need.

When Congress passed healthcare reform, one key protection for patients was a requirement that insurers cover a minimum set of “essential” benefits. Another protection banned insurers from discriminating based on health status. Despite these protections, many of the insurers offering plans on the new insurance exchanges are shifting the cost burden of medications to patients.

Put simply, Congressional intent is being ignored.

That’s why lawmakers must step in to make sure the Department of Health and Human Services updates its essential health benefits rule. Congress must also call on HHS to provide guidance to states that are being asked to assess whether exchange plans are discriminating against certain patients.

All exchange plans are required by law to cover prescription drugs. Each insurer maintains a list of prescription drugs — a formulary — that specifies the drugs it will cover. But most formularies have four or more “tiers” of coverage that place increasing cost-sharing obligations on patients. The surprise comes when you develop a condition whose medications fall into the top tier.

The first tier, usually for the most commonly prescribed medications, might include a modest copay of, say $20. But the highest tier typically involves co-insurance, in which the patient is responsible for a fixed percentage of the cost of a drug. The coinsurance percentage can run to 40 percent or more for drugs that can costs thousands of dollars.

This means that patients can get stuck with huge bills. The impact falls disproportionately on patients with serious conditions that require expensive medications, such as cancer, multiple sclerosis, and HIV/AIDS.

Indeed, a recent study by Avalere Health analyzed 123 mid-level exchange plans and found that more than 60 percent place all medication for cancer and other life-threatening conditions on the highest cost-sharing tier.

These formularies seem discriminatory, but HHS hasn’t stepped in to crack down on insurers. Congress must call on federal officials to make clear that discriminatory coverage is prohibited.

Such high out-of-pocket drug costs threaten to put necessary treatments out of reach for the patients who need them most. Patients are left with little choice but to deplete their savings or retirement funds, declare bankruptcy, or skip or refuse treatments.

Researchers at Duke University Medical Center surveyed cancer patients to learn how they coped with these costs. Nearly half described the financial burden as “significant” or “catastrophic.” Forty-six percent had to cut back on basic needs such as groceries.

The greater the cost-sharing, the more likely a patient will postpone or forgo medication. According to a study by University of North Carolina researchers, patients with higher co-payments were 70 percent more likely to stop taking their cancer treatment and 42 percent more likely to skip doses.

This is a serious, life-threatening problem. Skipping treatments significantly increases the risk of relapse. Missing even just 15 percent of a prescribed dose can lead to a recurrence of the cancer.

Getting a colon cancer diagnosis is bad enough without adding exorbitant out-of-pocket costs for treatment.  If the new health law is to live up to its promise of affordable care, Congress must create a solution and help people get the care they need and deserve.

Jasmine Greenamyer is the Chief Operating Officer of the Colon Cancer Alliance.

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