By Rep. Sylvia Ortiz
Represents Assembly District 8
Sylvia Ortiz
Time and time again, I hear from my community and those I represent in Assembly District 8 who are forced to make difficult decisions between affording the medications and treatments they need to survive, and other essential expenses. This issue is elevated even higher for individuals with chronic illnesses who see no end in sight from mounting medical bills.
Fortunately in the past 10 years, we have seen a lot of advancement in medicine to help folks with chronic illnesses live a productive and fulfilling life. In this time, the Food and Drug Administration (FDA) has approved more than 10 new treatments for cancer, as well as a new medication that targets the underlying cause of cystic fibrosis.
These significant advancements in medicine are also accompanied by a significant price tag. To assist patients in making ends meet while also paying for their medications, pharmaceutical manufacturers and non-profits created copay assistance programs, which helped to reduce out-of-pocket costs for medications and related care. In practice, the savings provided by the program would also go toward a patient’s deductible, and once that is hit, insurance would cover the remaining bill.
This assistance program provides patients with chronic diseases with a little more breathing room in their budgets, and given the disparities among folks who have medical debt, this program also addresses health equity. According to a report by the AIDS Institute, people of color, people with lower incomes, and individuals with chronic illnesses are more likely to have medical debt.
The copay assistance program has the potential to move us toward a more equitable health care system, but unfortunately, this is not our reality. A few years ago, Pharmaceutical Benefit Managers (PBMs) found a way to make many medications ineligible for copay assistance by deeming new treatments “non-essential,” even though there are not yet any generic options available. As a result, while insurers will still accept money from the assistance programs, they are not forced to count this toward a patient’s deductible.
A program intended to lessen the patient’s financial burden and play a role in reducing health inequity is only furthering the gap. Even worse, most patients don’t know that their health plan has a co-pay accumulator until they receive a bill with an unexpected balance after they thought they had reached their deductible.
This is why I, along with my colleagues on both sides of the aisle in the State Legislature, have introduced Assembly Bill 103 to end the copay accumulator program in Wisconsin and deliver the relief patients across Wisconsin need and deserve. Specifically, the bill would hold health insurers accountable in counting copay assistance toward an individual’s deductible.
Action at the federal level is also needed. Fortunately, H.R. 5801, the Help Ensure Lower Patient (HELP) Copays Act, has already been introduced in Congress with bipartisan support, but it still has not passed.
For patients with chronic illnesses, communities of color and individuals with lower incomes who have higher rates of overwhelming medical debt, copay assistance programs are a critical step toward health equity. We must protect patients and hold insurers and PBMs accountable by taking action at the state and federal levels.