A new report bolsters the premise that pervasive deficiencies persist in how Affordable Care Act (ACA) marketplace insurance plans treat the coverage and pricing of HIV medications, according to Carl Schmid, deputy executive director of The AIDS Institute (TAI).
“What NASTAD has done is take a look at all the drugs and all the plans around the country -- and this report is showing some shocking results,” Schmid recently told Patient Daily News.
The report, Discriminatory Design: HIV Treatment in the Marketplace, from the National Alliance of State and Territorial AIDS Directors (NASTAD), is aimed at assisting the current review of plan designs for 2017 by states and the Centers for Medicare & Medicaid Services (CMS), which are trying to reduce discriminatory plan design for patients with HIV.
Specifically, the report highlights the direct relationship between drug prices and insurer restrictions, underscoring the need for comprehensive drug pricing reform, as well as monitoring and enforcement of non-discrimination protections.
“The ACA has expanded access to medical care and prescription drug coverage for millions of Americans, revolutionizing coverage options for persons living with HIV,” according to the report. “Access to coverage, however, does not mean that coverage is high-quality or affordable.”
In fact, for people with HIV, antiretroviral therapy (ARV) is the cornerstone of maintaining their HIV treatment, but too often, qualified health plans available under the ACA fail to provide robust ARV coverage, according to NASTAD.
Some of the key findings in the report show that: 20 percent of health insurance plans on the Obamacare exchange only cover one single-tablet regimen, Atripla, which is the oldest and least-recommended regimen; one-third of plans place all covered single-tablet regimens on the specialty tier; more than 45 percent of Bronze plans subject all covered single-table regimens to co-insurance; 15 percent of plans don’t cover any HIV drugs that have been introduced since 2013; and increases in drug list prices lead to increased frequency of co-insurance at statistically significant levels.
“Despite all the things that the federal government is saying to the plans that you can’t do, it seems that they’re doing it still,” Schmid said.
In fact, TAI calls these practices “blatant discrimination,” particularly against people with chronic conditions who rely on prescription medications to remain healthy.
For instance, Schmid said that TAI has witnessed plans that limit access to critical medications through narrow formularies that don’t follow treatment guidelines and others with high patient cost sharing. Plans also force patients who are stable on one medication to switch mid-year to another for non-medical purposes. And some plans are placing all or almost all medications to treat a certain condition on the highest cost tier.
“The plans know they’re under scrutiny, and the feds have said ‘if you place every drug regimen for HIV on the highest tier, then it’s discrimination,’” Schmid said. “Yet NASTAD is showing that a number of the plans are still doing that.”
The bottom line, he said, is that better enforcement of discrimination provisions under the ACA and other federal laws is needed by both the states and the federal government when they review these plans.
“Every plan is supposed to be reviewed at the state level and federal level before they’re certified for operating, and it just shows that they are not doing an adequate job of enforcing what they’re saying should be occurring,” Schmid said.
And while there are strong non-discrimination provisions in the ACA, he said some people have had to file claims to have action taken on their behalf.
“They shouldn’t have to rely on advocates and legal people to get the plans to be compliant with patient rights,” Schmid said.
The pattern of limiting beneficiary access to medications through adverse tiering, for instance, is happening across the country not only for HIV, but also for hepatitis and other chronic conditions, according to Schmid, who pointed to an updated analysis by Avalere that found 31 percent of 2016 Silver plans placed all multiple sclerosis drugs and 50 percent placed all anti-angiogenic drugs on the highest formulary tier.
“You cannot deter people from getting insurance or enrolling in a plan based on their health status,” Schmid said. “That’s discriminatory and that’s against the law.”
The NASTAD report is available online at www.nastad.org.