Texas Legislature: A Solution Might Help Cure Chronic Disease Treatments Without Rationing

If anything, we should be applauding the scientific innovation and new discoveries over the past decade

AUSTIN, Texas (Texas Insider Report) — For years we’ve heard politicians from both sides of the aisle talk about ways to fight the increasing cost of healthcare.  But a lot of time has passed and if anything, the situation has gotten worse.

Thanks to inflation rates reaching heights not seen since the 1980’s, Americans are having trouble affording just about anything from food to gas to utilities.  It’s one thing to go without eggs for breakfast, but it’s an entirely more serious matter if people with chronic diseases are forced to ration – or go without lifesaving medicine.

Thanks to a new program created by insurers and pharmacy benefit managers (PBMs), more Texans are being forced into that precarious position.

It doesn’t have to be this way, and it shouldn’t.  If anything, we should be applauding the scientific innovation and new discoveries over the past decade that have created opportunities for people diagnosed with cancer, diabetes, cystic fibrosis, ALS to live longer and fuller lives.

But medical advancements are only effective if those who need them can access them, and cost is a huge barrier to overcome.

In 2023, the maximum a person can pay out of pocket for healthcare costs is $9,100 – $18,200 for a family. And according to the U.S. Census, the Median Household Income in Texas is $67,321, so it’s not likely that most families – especially those impacted by chronic disease – can afford to pay that much out of pocket.

So how do people afford their medications?

In the recent past, patients have been supported with copay assistance programs – coupons, vouchers, cards from nonprofits and even pharmaceutical manufacturers. These co-pay assistance programs limited out-of-pocket expenses for patients in two ways.

First, they reduce the cost to fill prescriptions at pharmacies. Then for insurance, the difference in cost may also be applied to the patient's annual out-of-pocket maximum or deductible.

It wasn’t the solution, but it was a fix. And, insurers and pharmacy benefit managers (PBMs) saw an opportunity to make an extra buck.

Copay Accumulators – a few new lines snuck into most people’s Insurance Plans a few years back – restrict the eligibility of copay assistance funds on out-of-pocket maximums or deductibles for some newer specialty drugs like those used to treat cancer, rheumatoid arthritis, lupus etc., causing copay adjustment programs to punish high cost sharing and co-insurance plans.

Despite the policy's intention to encourage cheaper treatments, 79% of branded medications with available co-pay assistance do not have generic equivalents. This means that patients will receive inadequate coverage on necessary medications – and unintended consequences from drops in adherence.

According to the Annals of Internal Medicine, 20-30% of prescriptions are never filled.

The New England Journal of Medicine estimates that this drop in adherence is costing the American taxpayer approximately $100 billion to $290 billion annually. 

Regrettably, co-pay accumulator programs have received very little attention – despite their enormous consequences for the health and wealth of Texans.

The good news is that Texas State Representative Four Price has filed HB 999 that will ban the practice and ensure members of our community receive the treatment they need.