States have figured out drug and copay reforms — Senate, follow their lead on AHCA

Recently, large insurers withdrew from the healthcare marketplaces and did so politically to get what they wanted out of Congress — the House passage of the American Health Care Act (AHCA) with provisions to: exclude Americans with health conditions that cost more to cover; charge more based on preexisting conditions; and offer lower quality of care. Moreover, the Congressional Budget Office’s newly released estimate report shows that the majority of spending in the AHCA would result from repealing taxes on health insurers.

On the plus side, the AHCA contains important reforms to stabilize the marketplaces (changing the Affordable Care Act’s age rating ratio from three-to-one to five-to-one, providing a strong incentive for healthy people to buy insurance and expanding tax-free health savings accounts). Yet, now that the bill has been delivered to the Senate, federal policymakers have the opportunity to learn from the states in offering reforms that are even more meaningful.

{mosads}For instance, for the 15.5 million Americans with cancer, Senate lawmakers could follow the lead of 43 states and the District of Columbia, which passed oral parity laws to equalize patients’ out-of-pocket costs for oral and IV therapies. This action is necessary because oral anti-cancer therapies are covered differently by insurers than IV drugs, meaning patients taking oral chemotherapy often pay more — up to 50 percent in some cases — with no annual out-of-pocket limit. As a result, one study found that 10 percent of these individuals do not fill their prescriptions due to the added cost burden, thus hampering their treatment.

The Senate can also look to the states in addressing “step therapy.” This is a common insurance practice requiring patients to try one or more less expensive drugs first and “fail” on them before the plan will cover the prescribed medication. Step therapy keeps practitioners from providing individualized care and may cause patients to suffer unnecessarily. For example, a health plan recently required a Texas woman with rheumatoid arthritis to fail on five different medications that undertreated her symptoms. Yet, the insurer still would not cover the medication her doctor ordered, insisting she fail on additional drugs first.

Health plans say step therapy keeps costs down for members. However, multiple studies show the practice increases the costs to the health system by exposing patients to less effective medications, delaying physician-recommended treatment and causing disease progression. Basing treatment decisions on cost rather than clinical considerations also ignores important variations that may exist among patients in terms of safety, efficacy and tolerability in drug classes.

Currently, at least 18 states have enacted laws that give physicians authority to override step therapy requirements based on a patient’s medical history, including legislation enacted this year in Iowa and Arkansas. The Arkansas law goes a step further by preventing insurers from requiring patients to try a drug that they failed on before, even if the person changes plans. The AHCA could standardize this practice nationwide and return clinical decision-making to providers and patients.

States also provide a model for the Senate to reduce the high copays many Americans now pay for their medicines. Health plans often put specialty medicines — newer and complex medications that treat challenging, chronic conditions such as cancer and HIV  — on the highest pharmacy tier and require copayments that could be thousands of dollars per month. Because of these high costs, several states passed laws to cap monthly copayments for patients with costly health conditions. This includes DC, which recently enacted legislation to cap copayments for specialty drugs at $150 a month.

DC’s law comes after advocacy organizations filed complaints against plans, arguing that placing all specialty medicines for a specific disease, like HIV, in the highest cost tier, is a form of discrimination. As such, the law, which will go into effect starting in January 1 expressly prohibits discrimination based on a person’s health condition.

At a time when the U.S. House has voted to put insurers’ interests ahead of consumer protections, state laws can provide a model for the Senate to reform healthcare in a way that adequately serves patients’ needs. Acting on step therapy will allow practitioners in conjunction with their patients to determine which treatments patients receive, while oral parity and the cap-the-copay laws will ensure that sick Americans can afford to access the medications they are prescribed.

Stacey L. Worthy, Esq., is executive director of the Alliance for the Adoption of Innovations in Medicine (Aimed Alliance), a nonprofit organization focused on expanding access to quality health care. Worthy is also healthcare attorney and partner at DCBA Law & Policy. Follow Aimed Alliance on Twitter @aimedalliance.

The views expressed by contributors are their own and are not the views of The Hill.