Actuarial studies of plans sold through health
insurance marketplaces in some states found that many make consumers
responsible for as much as 50 percent of the price of specialty
drugs, which can cost $8,000 or more a month.
Long before the U.S. Patient Protection and Affordable Care Act,
known as Obamacare, became law in 2010, insurers began replacing
fixed-dollar co-payments for the drugs with co-insurance rates that
require consumers to pay a percentage of the cost of specialty
Insurers say they had to move toward greater cost-sharing due to
higher prices for new drugs, some of which can cost more than
$100,000 annually per patient.
Researchers also say the higher rates help insurers bankroll low
monthly premiums to attract healthy young enrollees.
"Research shows that spending on specialty drugs is expected to
significantly increase. Therefore, any discussion of prescription
drug coverage must also include a focus on the direct link between
rising prescription drug prices and consumer cost sharing," said
Clare Krusing, spokeswoman for America's Health Insurance Plans, a
trade and lobbying group.
THE CHRONICALLY ILL
The healthcare overhaul, Obama's signature domestic policy
achievement, bars insurers from denying coverage to people due to
prior illness. The law protects the chronically ill from insurer
practices that limited their annual medical benefits but did not cap
their out-of-pocket expenses, the Department of Health and Human
Services said in a statement.
Obamacare caps those expenses at $6,350 for individuals and $12,700
But patient advocates say the spike in cost-sharing means
chronically ill people could reach those caps quickly, in some cases
within the first months of coverage.
"In the past, we've seen 10 or 20 percent coinsurance rates. Now
we're seeing 30, 40 and 50 percent. So patients are being asked to
bear more of the cost," said Brian Rosen, senior vice president for
public policy at the Leukemia & Lymphoma Society, which commissioned
actuarial firm Milliman Inc to study the new plans.
"Patients are going to spend their entire out-of-pocket cap before
they ever see a dime from the insurance company," he added.
Opponents of Obamacare have sought to use the difficulties faced by
the chronically ill in congressional elections this year. A
television campaign funded by a conservative group, Americans with
Prosperity, recently featured women with leukemia and lupus who say
they face unexpected costs due to Obamacare.
Patient advocates, however, insist that the law is not directly to
blame for higher charges on specialty drugs.
"The Affordable Care Act is great," said Dr. Patience White, a
rheumatologist and vice president for public health policy and
advocacy at the Arthritis Foundation. "Insurance companies now have
to take people with chronic illness. But they have investors and
can't lose money. That's the way American healthcare is."
WINNERS AND LOSERS
Among people with preexisting conditions, winners and losers have
emerged from Obama's overhaul of the U.S. healthcare system. Nearly
4 million people have signed up for the Obamacare plans, and the
enrollment period for 2014 ends on March 31.
One of the winners is Robert Ruffino, who is among the 1.1 million
Americans who suffer from blood cancer. The 45-year-old sales
manager from Baton Rouge, Louisiana, has had chronic myelogenous
leukemia for a decade.
Ruffino's individual policy previously cost him $13,000 to $19,000 a
year in monthly premiums, co-payments and coinsurance charges for
drugs, blood tests and specialist visits. When the law's provisions
on preexisting conditions took effect in 2014, he was able to join
his wife's employer-sponsored family health plan, which had modest
"It's a no-brainer," Ruffino said. "We have so much more flexibility
and options to gain insurance. Before, we were virtually locked
But that may not be the case for other patients who need specialty
drugs to keep chronic illnesses at bay.
[to top of second column]
The Milliman study on the health exchange plans in California,
Texas, Florida and New York found coinsurance rates of 40 and 50
percent for specialty drugs in two states whose Republican leaders
have sought to thwart Obamacare.
Plans from Aetna Inc, Humana Inc and Cigna Corp, three major
publicly traded insurers, accounted for some of the highest
coinsurance rates in Texas and Florida.
Some bronze-level plans, the least expensive in the state exchanges,
in those states charged no coinsurance or co-pay for specialty drugs
but had deductibles at or near the law's out-of-pocket maximum costs
California and New York, which were quick to embrace the Obamacare
marketplaces, had substantially lower specialty drug costs. Most of
California's coinsurance rates were below 30 percent, while New York
insurers charged co-pays of no more than $70.
A separate study of 19 states by consulting firm Avalere Health
said most health exchange plans require consumers to pay coinsurance
rates for many specialty drugs and that many plans also charged high
Avalere said 59 percent of mid-range silver plans and 38 percent of
top-quality platinum plans had coinsurance rates for specialty
drugs. Sixty percent of bronze plans had coinsurance rates greater
than 30 percent, it said.
"These cost-sharing levels are considerably higher than the
cost-sharing that is typically seen in the commercial marketplace,"
Avalere Chief Executive Officer Daniel Mendelson said. "We're at
this crux where we have to ask ourselves what we want insurance to
cover, what we want insurance to be."
Among the people who say they have suffered since the healthcare law
went into effect, Emilie Lamb has become one of the faces of
Americans for Prosperity's attack on Obamacare.
The 40-year-old Tennessee accountant and lupus sufferer is among the
women featured in the political group's ads, which the media has
criticized for overstating or not supporting its claims.
Her ad claims Lamb's annual health insurance costs went up more than
$6,000 as a result of Obamacare. She says that number is actually
$4,400, after she learned four of her six prescription drugs were in
fact covered by her Obamacare plan.
She now has a $373 monthly premium, no deductible and a $1,500
cap on out-of-pocket expenses, but the higher cost requires her to
work a second job. Lamb, who voted for Obama because she wanted
healthcare reform, called the law a disaster.
"I don't know what to do other than repeal it and start over," she
Lamb's former health plan, however, was unusually inexpensive,
costing only $53 a month in premiums with modest co-pays that added
up to about $1,000 a year. It capped coverage at $25,000 annually,
compared to her current plan, which has no benefits limit.
The average annual cost of treating lupus cases more severe than
Lamb's can reach $63,000, according to a 2011 study published in the
journal Arthritis Care and Research. An estimated 1.5 million people
have the disease in the United States.
(Reporting by David Morgan; Editing by
Michele Gershberg and Amanda Kwan)
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