Protecting Our Right to the Right Medicine
Sep 24, 2012 | 819 views | 0 0 comments | 288 288 recommendations | email to a friend | print


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 

side effects.


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 

effective treatments.


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 


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