A new report says that health insurance companies discriminate against people with hepatitis B and C by charging high out-of-pocket costs for drugs, but the industry lobby has called the analysis “very one-sided” and limited in scope.
The Affordable Care Act prohibits health insurers from discriminating against people on the basis of age, gender or health conditions, and the federal government has already made it clear it will monitor health plans sold on the public exchanges to ensure they meet ACA standards.
The not-for-profit AIDS Institute examined silver-level health plans that were sold on Florida's insurance marketplace in 2015. The group found that eight of the 12 insurers that sold 2015 plans had what it deemed as discriminatory practices for hepatitis B and C drugs. For example, Aetna placed many of its hepatitis drugs on the most expensive tiers with coinsurance rates up to 50%. Humana had a $1,500 prescription drug deductible and also had many of its hepatitis drugs on the highest tiers with large cost-sharing, the report found.
Two insurers, Florida Blue and UnitedHealthcare, were found to have “reasonable” cost-sharing plans in which copays never exceeded $160 and were often less.
In a statement, Humana said it provides access to affordable plans in a nondiscriminatory manner. “Our benefits are designed to balance overall affordability with specific drug coverage policies that seek to manage the very high cost of certain specialty drugs,” the statement reads. “This is a complicated matter that many others across the healthcare system, including state Medicaid agencies, are grappling with today.”
Previously, the AIDS Institute said insurers were illegally discriminating against patients who had HIV by making drugs unaffordable. The pressure on so-called “adverse tiering” led to Aetna and other insurers changing their policies on exchange plans earlier this year.
“The goal was to show to regulators and the insurers, too, that it's not just HIV in Florida, and the problem isn't fixed,” said Carl Schmid, deputy executive director of the AIDS Institute. “(Insurers) are not supposed to be deterring patients, and that's what they're doing.”
More than 4 million Americans have hepatitis B or C, which are viral infections that attack the liver, according to the Centers for Disease Control and Prevention. Sovaldi and Harvoni, two breakthrough hepatitis C drugs, captured the national spotlight last year because of their medical efficacy and their extremely high prices. However, the AIDS Institute's report did not factor in those drugs because 2015 plans did not include the new hepatitis C drugs in their formularies.
America's Health Insurance Plans, the lobbying group for health insurers, criticized the report, which did not look at other plans with richer benefit designs and looked only at drug coverage. People who earn between 100% and 250% of the federal poverty level and who buy silver-level plans are also eligible for cost-sharing subsidies that lower their out-of-pocket costs.
“All individuals, regardless of health status, have access to coverage,” AHIP spokeswoman Clare Krusing said in an e-mail. “A key component of the marketplace is consumer choice. Individuals have diverse health and financial needs, and health plans have designed a wide-range of coverage options, including those with lower cost-sharing, so individuals can pick the policy that is best for them.”
AHIP also said the AIDS Institute receives money from drug companies and therefore did not address the underlying issue of high drug pricing.
The AIDS Institute receives funding from not-for-profit foundations as well as pharmaceutical companies, Schmid said. He declined to name which drugmakers provide money but said they have no say in their research. “We didn't get paid to do this work,” Schmid said.
Next year's open enrollment starts Nov. 1, and the CMS has said it will closely scrutinize health plans that use high-cost tiers for drugs. The government has acknowledged that tiers for specialty drugs are not discriminatory on their own, but they could be if patients have to shoulder a lot of the payments.
“If an issuer places most or all drugs that treat a specific condition on the highest cost tiers, that plan design might effectively discriminate against, or discourages enrollment by, individuals who have those chronic conditions,” the federal agency told insurers.
Patient advocates are hoping the CMS will live up to its word and more closely monitor health plans that abuse drug tiers. “It's a problem that started from the get-go and has continued,” said Amy Killelea, director of health systems integration at the National Alliance of State & Territorial AIDS Directors. “We're hoping that the feds have taken notice.”