President Obama’s healthcare reform is about to severely restrict drug treatment
options for millions of America’s most vulnerable patients.
This certainly wasn’t the president’s intention. But a new, preliminary
regulatory ruling from the Department of Health and Human Services required by
the 2010 healthcare reform law applies a one-size-fits-all approach to
prescription medicines. And the result could be substantially fewer treatment
options for Americans all across the country.
Instead of requiring insurance companies to cover whatever medicine a physician
deems appropriate, the HHS would only require them to cover a single drug in
each class of pharmaceuticals. So for example, if an HIV patient reacted badly
to a particular anticonvulsant, he could be out of luck trying to get another
one paid for by his insurance plan.
If HHS’s preliminary guidance becomes law, it’s likely to harm patients and
drive up healthcare costs. The proposed HHS approach is particularly problematic
for patients living with chronic conditions, including HIV/AIDS, severe mental
illness, diabetes, and cancer; covering just one drug is wholly inadequate to
meet their complex needs.
There’s a way to do it better, making sure patients have access to the right
medicines while keeping costs under control. In fact, we already have a model
for how to make it work in Medicare Part D.
Implemented in 2006, Part D is a prescription drug benefit offered under
Medicare, our system of government-subsidized health care for seniors. It
requires competing insurance plans to cover nearly all drugs in six critical
classes: immunosuppressants, antidepressants, antipsychotics, anticonvulsants,
antiretrovirals, and antineoplastics.
Ensuring access to a wide range of drugs is particularly important for the HIV
community. Every patient suffering from the disease exhibits unique symptoms,
and it’s not uncommon for doctors to try a variety of drug regimens before
determining the one that will work best. It’s also likely that patients
suffering from chronic conditions, including HIV/AIDS, will require a
combination of several drugs.
Furthermore, patients can easily develop hypersensitivities or adverse side
effects from their first-line drug treatment. This is the case for many HIV
antiretrovirals, which are known for their harsh side effects. In fact, it’s not
uncommon for patients to take ten or more additional pills just to manage their
Patients can easily require multiple medications in more than one class of
pharmaceuticals throughout their course of treatment. Covering just one drug per
class will make it financially impossible for many patients to receive the
cocktail of medicines they need, and may force patients to discontinue the most
Research into drug access for Medicaid beneficiaries also starkly illustrates
just how dangerous restricted access to medications can be. Medicaid enrollees
with problems accessing the drugs they need are far more likely to exhibit
suicidal behavior, or experience homelessness and incarceration.
In addition to harming patients’ health, restricting the number of available
drugs drags down our health care system. Patients whose conditions are not
addressed by the single covered drug in each class are more likely to experience
relapses in their illnesses, exacerbating symptoms and requiring more
hospitalizations, re-hospitalizations and expensive acute care.
In fact, Medicaid beneficiaries with drug access problems are 74 percent more
likely to visit an emergency room for treatment and when they do, tend to
require 72 percent more acute inpatient days in the hospital. Annually, these
hospital stays end up costing more than twice the annual spending on the
prescription drugs that the patients should have been taking in the first place.
It makes little sense to implement regulations that will cost more and increase
the number of patients in hospital beds.
Part D, on the other hand, has been saving taxpayers and patients alike. The
program’s costs have consistently come in below Congressional Budget Office
projections. In fact, beneficiaries’ average monthly premiums for 2012 are lower
than they were last year.
HHS will soon make its final ruling on what drugs insurers must cover. To
protect patients’ health and control costs, it’s critical that officials revise
their current, restrictive proposal. Instead, they should take a page from
Medicare’s successful Part D.
Frank Oldham is President and CEO of the National Association of People with