Time to promote fairness and transparency in healthcare

After over five years of vigorous debate, more than 50 congressional votes, a presidential election, and two Supreme Court decisions, the fate of the Patient Protection and Affordable Care Act (ACA) has finally been sealed with last week’s King v. Burwell decision. The healthcare law is here to stay. Now, it is time to move beyond the tired debates of the past and look for ways to strengthen the law to make it work better for all Americans.  

The ACA has made great strides in promoting access to health care by prohibiting insurers from denying enrollment based on preexisting medical conditions or disability. Under the ACA’s nondiscrimination provision, marketplace health plans cannot discriminate or structure benefits so as to discourage enrollment against certain patient populations. Yet, there is still much more work to be done to address abusive practices by insurers that are seriously affecting access to treatment. These cost-saving measures often discriminate against patients with critical and chronic illnesses, who often have the greatest needs for health care coverage. 

{mosads}For instance, fail-first policies, also known as step therapy, require patients to take specific medications for a particular condition, regardless of what the patient has been prescribed by a health care practitioner. Patients must prove that they have “failed” less expensive treatments that are often inferior to the one prescribed in order to qualify for treatment that is more effective, yet often more expensive. Timely access is vital for many conditions, and fail-first policies put lives at risk when patients do not receive the medications they need at the right time.  

The growing use of over-burdensome prior authorizations has also become an issue. According to an American Medical Association survey, doctors spend on average 20 hours a week filling out authorization paperwork for medications and tests — time better spent on caring for patients. With a shortage of health care providers nationwide and 12 million more Americans with health insurance, obstacles like these undermine the entire ACA system of care by discouraging providers committed to quality and efficiency from accepting insurance altogether. 

Additionally, drug formularies that prioritize one drug over another result in high cost-sharing for patients, including as much as 50 percent copayments. Some insurers have used these so called specialty tiers as a way to deny care to individuals in certain patient populations, thereby circumventing the ACA’s prohibition on denials for preexisting conditions. For instance, the National Health Law Program and the AIDS Institute recently filed a complaint with the U.S. Department of Health and Human Services against four Florida insurers (CoventryOne, Cigna, Humana, and Preferred Medical) for placing all HIV medications in the highest tier of their formularies and charging patients copays of more than $1,000 a month. As a result, Florida’s insurance regulators announced that they will review insurance plans for possible discriminatory practices. 

Insurers have also placed blanketed restrictions on access to treatment. For instance, over the past two months, lawsuits have been filed against Florida Blue and Anthem Blue Cross in California because the insurers denied access to a virus-curing hepatitis C medication. In three separate cases, the plaintiffs alleged that they were denied access to the cure because they were told they had not sustained insufficient liver damage. In essence, the insurers insisted that they become sicker and run the risk of developing further health complications before they would grant access to a treatment that has become the standard of care. 

Price transparency in health care also continues to be a growing concern. According to a 2014 report, stated that 90 percent of states failed to make adequate pricing information available to consumers, despite requirements set forth under the ACA. To make matters worse, insurers are still able to issue mid-year formulary changes, leaving patients to deal with greater costs in accessing their medications or worse yet, lose coverage for their medication altogether if it is dropped from the formulary. Consumers choose plans by reviewing coverage and calculating their out-of-pocket expenses. Mid-year formulary changes set consumers up for bait-and-switch exploitation. 

Now that we can acknowledge that the ACA is here to stay, it is time to come together and address the law’s shortfalls so that it can truly accomplish what it set out to do: protect patients and provide them with access to quality, affordable healthcare.  

Worthy is the director of Public Policy at the Alliance for the Adoption of Medicine (Aimed Alliance). Garza is the manager of Policy and Advocacy at Aimed Alliance.