Tuesday, November 15, 2022


As COVID-19 has dominated health care resources over the past several years, people living with chronic illnesses have faced even greater problems getting the health care they need.

Resources were shifted to combat coronavirus, but in the wake of those decisions, patients with chronic illnesses fell by the wayside. The National Library of Medicine’s National Center for Biotechnology Information published a paper on the impact of COVID-19 on chronic disease care. It found the pandemic created barriers that reduced access and hospitalization for patients with chronic conditions, which made it more difficult for patients to get new diagnoses and manage their conditions.

Patients with chronic illnesses are facing the full brunt of high out-of-pocket costs. The way insurance is designed leaves patients on the hook for their health care expenses, which they often cannot fully afford. Drug manufacturers provide patients with copay assistance, which allows patients to have affordable access to their doctor-prescribed medications by providing significant financial support to those who may not otherwise be able to pay for treatments — even if they have insurance.

Unfortunately, insurers and pharmacy benefit managers are increasingly choosing not to count copay assistance from drug manufacturers toward patients’ out-of-pocket maximums and deductibles. Patients will use their copay assistance for several months with no issues and then be surprised to find that their assistance has run out. Then they find that insurers and pharmacy benefit managers have siphoned these payments into their own pockets through schemes known as copay accumulator adjustment policies and copay maximizer adjustment programs.

These policies and programs contribute to an expanding gap between what patients can afford and how much it will cost to get their treatment.

Many patients who are subjected to copay adjustment programs abandon their medication and stop their treatments because out-of-pocket costs get too high. According to a study conducted by IQVIA, 61% of commercially insured patients did not fill their new prescriptions when their out-of-pocket costs exceeded $250.

Jim Turk, who has multiple sclerosis, has been outspoken on how copay accumulator policies have posed a threat to his health. Mr. Turk told the Milwaukee Journal Sentinel that “copay accumulator programs can be devastating to MS patients and those battling other conditions who could very well lose access to the drugs they rely on to maintain their health and well-being.” Patients are asking for help, and lawmakers should answer their call.

In a recent article, the Republican Healthy Future Task Force co-chairs, GOP Reps. Brett Guthrie of Kentucky and Vern Buchanan of Florida, provided an overview of the task force’s solutions. The co-chairs wrote that “Republicans are prepared to improve the American health care system by getting policies signed into law that will lead to more cures and choices, better care, and lower out-of-pocket costs for patients.” Republicans serious about getting policies signed into law that will lead to better care and lower out-of-pocket costs should start with copay adjustment policies.

Republican members of Congress and the Healthy Future Task Force can look to state governments for inspiration on how to solve the ever-growing issue of copay adjustment programs. Copay accumulators or maximizers have been outlawed in 14 states and in Puerto Rico. State legislators have taken action to protect vulnerable patients and communities from the schemes of insurers and pharmacy benefit managers.

Policymakers at the federal level also have taken notice. The HELP Copays Act, H.R. 5801, a piece of bipartisan legislation that would outlaw copay accumulator and maximizer adjustment systems, has already been proposed and would be the perfect opportunity for bipartisan cooperation between the two parties.

Republicans who are truly committed to a “Healthy Future” should ensure that the most vulnerable Americans are protected from the schemes of insurers and their middlemen.

• Brian McNicoll, a freelance writer based in Alexandria, Virginia, is a former senior writer for The Heritage Foundation and former director of communications for the House Committee on Oversight and Government Reform. 

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