- - Wednesday, January 29, 2014


Many Americans began this month with new health coverage purchased through Obamacare’s exchanges. At least, they thought they did — scores did not receive insurance cards or other confirmation that they actually had coverage.

The hang-up was largely a function of the technical glitches that have plagued the exchanges. Fortunately, several pharmacy chains, including Walgreens and CVS, decided to offer temporary supplies of prescription drugs to cardless customers who couldn’t afford their medicines.

But even after their cards arrive, patients with exchange coverage may not be able to get the drugs they need. That’s because the administration has yet to issue rules guaranteeing access to advanced medications.

If federal officials don’t act, many chronically ill patients will have to settle for inferior therapies — or forgo treatment entirely. Americans must speak out against such government-driven rationing of care.

One of Obamacare’s chief objectives was to improve access to care for those with pre-existing health conditions. The law prevents insurers from denying coverage to anyone who applies, regardless of health status or history. It also forbids insurers from charging older folks — who tend to have more health problems — more than three times what they charge younger people.

In order to comply with the law’s stringent rate regulations, many insurers have scrimped on what they’ll cover — especially prescription drugs.

So while people with pre-existing and chronic conditions may be able to get insurance through the exchanges, that coverage may not pay for the medicines they need.

Consider the widely used multiple sclerosis (MS) drug Betaseron. Under a midlevel, “silver” exchange plan offered by insurer Meridian Choice, an MS patient living in Kalamazoo County, Mich., would have to shoulder the entire $4,500 monthly cost of the medication.

Further, because the drug isn’t on the plan’s formulary, money spent on Betaseron wouldn’t count toward Obamacare’s cap on out-of-pocket spending.

Facing such high monthly costs, many patients will switch to cheaper, less effective treatments that are covered by their plan.

Even worse, some patients may stop taking their medications entirely. According to the Journal of the American Medical Association, doubling out-of-pocket costs for certain prescriptions for chronic conditions can lead to a 45 percent drop in adherence.

This isn’t just an issue of patient health; it has cost implications, too. Prescription drugs are among the most cost-effective tools in our health care arsenal. Columbia University professor Frank Lichtenberg estimates that an additional dollar spent on pharmaceuticals reduces hospital expenditures by $3.65.

According to a report published by the National Bureau of Economic Research, Medicare saves more than $2 for each dollar it spends on medicines.

By skimping on prescription-drug coverage and thus discouraging chronically ill patients from taking their medicines, Obamacare’s exchange plans will lead to higher overall health costs.

The Obama administration created these perverse incentives — and so it must fix them.

It can start by issuing guidelines to help exchange administrators recognize when a plan’s drug formulary focuses inappropriately on the sticker price of a medicine rather than the value that the drug delivers to the patient and the health care system.

Coverage of prescription drugs must also comport with accepted medical practice. At present, some exchange plans do not cover the standard single-tablet method of treating HIV, even though the regimen is considered “the most cost-effective treatment strategy,” according to a study published by the journal ClinicoEconomics and Outcomes Research.

Regulators should also require plans to consider newly approved medicines. These meds may have higher price tags than their older counterparts. If they’re more effective or quicker to treat a particular condition, though, they might be worth that higher price tag.

Finally, regulators should scrutinize plans with deductibles for branded medicines, but not for generics. For some patients, branded medicines may be medically necessary. Such deductibles are not needed to encourage the use of generics anyway, as they already account for 80 percent of prescriptions. In the end, the extra charges may result in patients receiving suboptimal care.

Obamacare was sold as a means of delivering affordable care to those who couldn’t get it previously. Yet the insurance available through its exchanges appears set to cut many chronically ill patients off from quality treatment. Americans must not stand for such rationing.

Sally C. Pipes is president, CEO and Taube fellow in health care studies at the Pacific Research Institute. She is the author of “The Cure for Obamacare” (Encounter, 2013).

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