Share This Page

Health care law can't suppress drug costs for sickest

| Saturday, March 22, 2014, 5:42 p.m.

MIAMI — Breast cancer survivor Ginny Mason was thrilled to get health coverage under the Affordable Care Act despite her pre-existing condition. But when she realized her arthritis medication fell under a particularly costly tier of her plan, she was forced to switch to another brand.

Under the plan, her Celebrex would have cost $648 a month until she met her $1,500 prescription deductible, followed by an $85 monthly co-pay.

Mason is one of the many Americans with serious illnesses — including cancer, multiple sclerosis and rheumatoid arthritis — who are indeed finding relatively low monthly premiums under President Obama's law. But some have been shocked at how much their prescriptions are costing as insurers are sorting drug prices into a complex tier system and in some cases charging co-insurance rates as high as 50 percent. That can leave patients on the hook for thousands.

“I was grateful for the Affordable Care Act because it didn't turn me down, but ... it's like, where's the ‘affordable' on this one?” said Mason, a 61-year-old from West Lafayette, Ind., who pays an $800 monthly premium.

Before the federal health law took effect, Mason paid slightly more for her monthly premium on a plan that did not cover her arthritis or pain medications and some routine doctor's visits.

Avalere Health, a market research and consulting firm, estimates some consumers will pay half the cost of their specialty drugs under health overhaul-related plans, while customers in the private market typically pay no more than a third. Patient advocates worry that insurers may be trying to discourage chronically ill patients from enrolling by putting high-cost drugs onto specialty tiers.

Brian Rosen, senior vice president for public policy for The Leukemia & Lymphoma Society, said the group studied premiums and benefits for patients with blood cancer in seven states, including Florida, California, Texas and New York. They found 50 percent co-insurance rates for specialty drugs on several plans in Florida and Texas, while the highest co-insurance rates on California plans were 30 percent, and in New York, co-pays were typically $70.

Under the law, insurers cannot charge an individual more than $6,350 in out-of pocket costs a year and no more than $12,700 for a family policy. But patients advocates warn those with serious illnesses could pay their entire out-of-pocket cap before their insurance kicks in any money.

“The challenge is for the sickest patients, the ones that need access to these specialty drugs, the costs are going to come in most cases from that out-of-pocket cap. ... They are likely to hit that $6,350 ceiling and in some cases quickly,” said Rosen.

Insurers say prescription drugs are one of the main reasons health care costs are rising.

“Spending on specialty drugs is growing rapidly. It's unsustainable,” said Clare Krusing, spokeswoman for America's Health Insurance Plans, a trade group that represents the private insurance industry.

Only 1 percent of prescriptions written in 2012 were for specialty drugs, but they accounted for 25 percent of the total cost of prescription drugs, according to a study by America's Health Insurance Plans.

TribLIVE commenting policy

You are solely responsible for your comments and by using TribLive.com you agree to our Terms of Service.

We moderate comments. Our goal is to provide substantive commentary for a general readership. By screening submissions, we provide a space where readers can share intelligent and informed commentary that enhances the quality of our news and information.

While most comments will be posted if they are on-topic and not abusive, moderating decisions are subjective. We will make them as carefully and consistently as we can. Because of the volume of reader comments, we cannot review individual moderation decisions with readers.

We value thoughtful comments representing a range of views that make their point quickly and politely. We make an effort to protect discussions from repeated comments either by the same reader or different readers

We follow the same standards for taste as the daily newspaper. A few things we won't tolerate: personal attacks, obscenity, vulgarity, profanity (including expletives and letters followed by dashes), commercial promotion, impersonations, incoherence, proselytizing and SHOUTING. Don't include URLs to Web sites.

We do not edit comments. They are either approved or deleted. We reserve the right to edit a comment that is quoted or excerpted in an article. In this case, we may fix spelling and punctuation.

We welcome strong opinions and criticism of our work, but we don't want comments to become bogged down with discussions of our policies and we will moderate accordingly.

We appreciate it when readers and people quoted in articles or blog posts point out errors of fact or emphasis and will investigate all assertions. But these suggestions should be sent via e-mail. To avoid distracting other readers, we won't publish comments that suggest a correction. Instead, corrections will be made in a blog post or in an article.