HIV Patients Asked to Pay More Under Obamacare

Advocates say insurers are finding new ways to squeeze patients with HIV

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One of the most popular provisions of the Affordable Care Act is the requirement that insurance companies sell policies to anyone who wants them, without charging higher premiums based on pre-existing conditions. But premiums are just a part of what Americans pay for health care and even under Obamacare, some people with underlying health issues are facing less choice and higher costs than those who are healthy.

More than two months after the launch of health law’s private insurance markets, Americans with pre-existing conditions like HIV are discovering that some of the policies being sold through Obamacare’s new insurance exchanges do not cover commonly prescribed medications for their disease and require much higher out-of-pocket spending than for other drugs. In many 2014 plans offered in the ACA’s insurance exchanges, that can mean patients are required to cover as as much as 50 percent of the cost of HIV medications, an expense that could run as high as $1,500 per month. (The health law caps annual out-of-pocket spending for individuals at $6,350.)

This kind of coinsurance for expensive medications, in which patients pay a percentage of total cost instead of a fixed copay, existed before the ACA, but experts say it could become more common under the law as insurers are forced to sell policies to sick and healthy consumers alike. These companies must compete in Obamacare’s new marketplaces, where consumers can easily compare premiums, but not coinsurance drug costs and other out-of-pocket spending.

Some HIV advocates see the limited offerings as part of an intentional move by insurers to scare away HIV patients in order to keep their risk pools full of healthy people and their profits up. “It’s blatant discrimination,” says Carl Schmid, executive director of the AIDS Institute, a non-profit advocacy organization based in Washington, DC. Others say insurance companies, many of which have little experience offering individual market coverage to those with HIV, may have simply overlooked certain drugs in their initial plan designs. “I’m going to give the insurers the benefit of the doubt,” says Robert Greenwald, co-chair of a national working group on HIV policy and director of Harvard’s Center for Health Law and Policy Innovation. “This is a new paradigm they’re working under.”

Either way, for those with underlying health conditions—including HIV—the process of choosing a new health plan under Obamacare is no simple matter. Rather, choosing a plan means navigating a maze of confusing and sometimes inaccurate medication lists and fewer viable insurance choices than those available to their healthier counterparts. “We wanted these protections for vulnerable populations and we’re not getting them,” says Schmid. “I don’t know want to knock the ACA because we support it, but we want it to work for patients.”

Of the six health plans offered through Illinois’ Obamacare insurance exchange, for example, just two offer accompanying prescription drug coverage that allow HIV patients to obtain prescription medications with copays of $50 or less, according to says John Peller, vice president of policy at the AIDS Foundation of Chicago. The other four plans, which Peller characterizes as “problematic,” require enrollees to pay 30 to 50 percent of the cost of HIV drugs.

Variation in drug coverage among health plans is common and legal, but advocates worry that the limited options for HIV patients could dissuade many from getting the coverage they need and can afford under the new law. “We have to be careful to hold all the insurers accountable so they do not implement practices that discourage people living with HIV from applying for their plans,” says Greenwald.

Federal regulations require that insurers cover a certain number of anti-viral drugs used to treat HIV, but do not specify which drugs must be included in a plan. Regulations require that drug coverage plans be designed in a non-discriminatory way, but allow insurance companies to classify drugs into difference “tiers” that require different levels of patient cost-sharing. In many cases, HIV drugs are classified as higher tier medications. A spokesperson for the Department of Health and Human Services said that patients can ask insurers to make exceptions for un-covered drugs.

In October, Greenwald spearheaded an effort to alert insurers and federal health officials that some drug coverage plans on the exchanges omitted combination single dose medications for HIV patients. These insurers instead covered individual HIV drugs, but most HIV patients prefer to take pills that combine several drugs into a single pill. “When patients are on single tablet regimens, their adherence goes up, their hospitalization costs goes down and their overall treatment costs go down,” says Peller. After Greenwald and others raised the issue publicly with HHS, several insurers added single dose medications to their drug lists, known as formularies. WellPoint, which sells plans through exchanges in 14 states, said it added one common single dose drug, called Atripla, to its formulary after Oct. 1.

Not everyone has followed suit, Greenwald says, and he notes that some insurers have not updated the lists of covered drugs that are publicly available to consumers shopping in the insurance exchanges. The omission, he says, “could rise to a discriminatory practice because it discourages people with HIV from applying because they don’t see their medications covered.” To Greenwald and other advocates, placing high coinsurance rates on all HIV drugs is a way of treating these patients differently than their healthy counterparts — despite the ACA’s promise to end discrimination against those with pre-existing conditions. “The whole point of the Affordable Care Act and these marketplace plans is to give people access to health care and essential health benefits that meet the standard of care,” says Greenwald. But for some HIV patients, he says, “The coverage will be meaningless because many people will not be able to afford their medications.”

Public funding programs help cover HIV health care and drug costs not picked up by insurance, but eligibility for such programs varies by state. “I’m very concerned that six months from now what you are able to get in Illinois is going to look very different in Alabama and that is not how one deals with an epidemic and a communicable disease like HIV,” says Greenwald. HIV patients who adhere to individually tailored drug regimens are far less likely to transmit the disease as their viral load drops.

Before the ACA, insurance companies could simply refuse to cover HIV patients, part of the reason some 25 percent of this population is uninsured and about half do not receive regular medical care, according to the Centers for Disease Control and Prevention. Peller, of the AIDS Foundation of Chicago, says half of those with HIV and AIDS in Illinois are currently uninsured and many will gain new coverage not through the ACA’s private insurance marketplaces, but through Medicaid. This public insurance program and other funding programs to cover costs not picked up by private insurers “really blunts the impact of some of these discriminatory plan designs,” he says. “But we feel very strongly that the coverage that exists in 2014 is really going to be the template for the future. We want to make sure that the plans that are out there are fair to people with every kind of chronic condition, including HIV.”

14 comments
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carolinabus6

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EddieHamilton
EddieHamilton

Even negotiated HIV drugs insurance prices are extremely high. The pharmaceutical companies are giving back rebates under the 340B program, Medicaid  and State AIDS drug assistance programs but insurance companies cannot be in that program- therefore, the insurance companies are making actuarial decisions. Don't get me wrong but this article is missing some crucial information to make accurate judgments.  I hate insurance companies and disagree with many of their practices but with government programs taking rebates on these drugs from insurance companies- the plans will never reflect a true anti-retroviral formulary. The government programs are using those rebate funds to pay for HIV non-drug related services.

emeraldseatown
emeraldseatown

You know what, we should make the insurance companies cover so much and charge so little that they will go out of business!


Then we won't have any middleman charging us for insurance, because we won't have any!

Irony
Irony

Decent article, horrible headline.


Key point is : "Before the ACA, insurance companies could simply refuse to cover HIV patients"


The headline implies this to be some sort of failing of Obamacare, as opposed to what it is: a substantial improvement whose only failing is that it does not go far enough.


And that is truly the biggest failing of Obamacare. It moves US healthcare from 3rd to 2nd world when we have the resources join the rest of the 1st.

MichelleStarr
MichelleStarr

They need to give the drugs to people who did not vote for Obamacare and not give them to those that did

StephenSchwartz
StephenSchwartz

If everything the author has told us true, then an additional ObamaCare tax is needed.  Millenials, turn your head and cough...

firmsoil
firmsoil

Harvard lawyer lie - "Affordable".

mantisdragon91
mantisdragon91

And this is why we need Single Payer. We are the only industrialized country that is still allowing Insurance Companies to gouge people for providing basic coverage.

mantisdragon91
mantisdragon91

Thanks Michell. You are a voice of Right Wing brilliance and a perfect illustration of why the party is a laughing stock world wide

StephenSchwartz
StephenSchwartz

@mantisdragon91 I wouldn't call treatment for cancer or heart disease "basic."  The treatment is a basic necessity in the lives of those who suffer the disease, but those are not "basic" products.  The drugs are appropriately priced and ridiculously expensive. Notice how you only find Pfizer facilities in places like Princeton and Ann Arbor?  Somebody has to pay for it, insurance companies are a business, and Obama couldn't make his millenial fanbase swallow that much of a pill.


Same goes for AIDS treatment.  

mantisdragon91
mantisdragon91

Insurance companies are only making 5%? Assuming that figure is even accurate which it isn't, they all have huge HQs and executives making millions. Wonder who's pocket those costs are paid from?

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